MAIN PURPOSE OF THE JOB: (JOB SUMMARY)
The Risk and Governance Manager is accountable for establishing and maintaining a comprehensive, proportionate risk, compliance, and complaints management framework throughout the organisation's MSK and Mental Health services. Reporting directly to the Quality and Clinical Governance Director and supervising the Compliance Lead and the Complaints Manager, this position ensures adherence to regulatory, contractual, and governance /clinical governance requirements, effective management of risks, timely resolution of complaints in line with PSIRF and best practice standards, and systematic application of lessons learned across all service lines.
This role is suited to an accomplished risk, compliance and complaints professional with direct healthcare experience in these areas and the capability to work autonomously and translate regulatory requirements into efficient, adaptable operational systems within a fast-growing private healthcare environment.
KEY TASKS AND RESPONSIBILITIES:
Risk Management
* Lead and maintain the organisation-wide risk management framework across MSK and Mental Health services
* Maintain and oversee corporate and service-level risk registers, ensuring consistency and regular review
* Support clinical and operational teams to identify, assess and mitigate clinical, operational, information governance and reputational risks
* Monitor risk themes, emerging risks and near misses, escalating concerns appropriately
* Contribute to learning from incidents, complaints, safeguarding concerns and serious incidents/PSIRF
Regulatory Compliance
* Act as a key lead for ISO and Quality compliance across MSK and Mental Health services.
* Support ISO registration, variations and audits, ensuring services are inspection-ready
* Maintain oversight of compliance with:
* Appropriate ISO Standards
* UK GDPR and Data Protection Act
* Information Governance
* Health & Safety legislation
* Contractual, client and insurer requirements
* Horizon scan for regulatory changes impacting MSK and Mental Health services and advise on required actions
* Conduct ISO audits and train staff to be able to conduct regular internal ISO audits
Complaints Management
* Lead, manage and oversee the complaints management process across the organisation in line with PSIRF and regulatory requirements and organisational policy
* Ensure complaints are acknowledged, investigated and responded to within required timescales
* As necessary, support service leads and clinicians with complaint investigations, response drafting and resolution
* Conduct level 4 complaints and appeals
* Ensure complaints are managed in a fair, transparent, compassionate and patient-centred manner in line with PSIRF
* Design the training content for PSIRF and support the Clinical Governance Leads to deliver organisational PSIRF training
* Support the Senior Complaints Officer to identify complaint themes, trends and emerging risks, ensuring learning is captured and shared
* Link complaints intelligence with risk management, incidents, safeguarding and audit activity
* Prepare complaints reports for Quality & Clinical Governance meetings, SLT assurance
* Compile responses to level 4 complaints and complaints escalated to clients, insurers or regulators
* Link into ISCAS and ensure a fair process for independent review
* Manage and lead on the Clear Track patient feedback system and review data to establish themes and quality improvement projects
Policies, Procedures & Controls
* Responsible person to lead develop, review and implementation of policies, procedures and SOPs, relating to quality, complaints, clinical governance, risk and compliance policies
* Ensure all organisational policies are accessible, proportionate and embedded
* Maintain a compliance calendar and evidence library and produce the necessary reports
* Ensure that the organisation has all the appropriate policies in place, especially in relation to PSIRF.
Audit, Assurance & Readiness
* Design and coordinate the corporate & ISO audit programme with the Quality & Clinical Governance Director and Quality Lead
* Conduct and support internal audits, mock inspections and service readiness reviews
* Support the Quality Lead to track audit findings, identified themes and assurance actions to completion
* Contribute to quality assurance and improvement initiatives arising from audit, complaints, feedback and risk activity
* Track audit findings, actions and assurance outcomes and produce quarterly audit reports
* Chair the Quality Assurance Group
Clinical Governance & Reporting
* Prepare clear, high-quality reports on clinical governance, risk, compliance and complaints for clinical and quality groups and the SLT
* Contribute to governance papers, assurance statements and external submissions
* Support the Quality Lead with ISO and client audits and due diligence activity
* Attend and support at the Clinical Governance meetings for both MSK and MH services
Training, Advice & Embedding Compliance
* Support the development and delivery of risk and compliance training for clinical and non-clinical teams
* Provide day-to-day advice to service leads, clinicians and operational teams on compliance and risk matters and maintaining robust risk registers
* Promote a strong risk-aware and learning culture across remote and networked clinical teams
* Support the Senior Complaints Officer with the development and delivery of training relating to complaints handling, complaints response, risk management and regulatory compliance
* Support the Quality Lead to provide advice and guidance to the clinical and operational teams
* Promote a learning culture focused on improvement, openness and duty of candour
PERSON SPECIFICATION
QUALIFICATIONS, TRAINING AND EXPERIENCE:
* Healthcare experience
* Clinical Governance and Quality Assurance and Improvement experience and recognised training
* Complaints management experience
* Risk management qualification
* Evidence of effective leadership skills
* Highly developed knowledge or equivalent experience in relevant areas e.g. governance, quality, risk, complaints
* Evidence of PSIRF training
EXPERIENCE AND KNOWLEDGE:
Essential:
* Knowledge and demonstrable experience of working within governance, clinical governance, complaints, quality and risk in private healthcare or the NHS.
* Knowledge of the components of governance and assurance, national policies, standards, requirements and directions that relate to identifying, measuring and improving the quality of patient care.
* Responsible for the development and implementation of a range of policy and guidelines in relation to the Governance and Risk Management Framework across the organisation- this will involve writing, implementing and overseeing how these are embedded and utilised.
* Demonstrable ability to train others in relevant areas
* Strong working knowledge of ISO regulation, auditing and duty of candour requirements
* Experience establishing and managing complaints processes, complaints audits and complex investigations in a Healthcare environment
* Experience with producing and training on risk registers, risk auditing and assurance reporting
* Strong written communication skills, including experience of drafting complaint responses
* Experience and demonstrable experience of PSIRF
* Experience and qualification of ISO auditing
Desirable:
* Experience across MSK and/or Mental Health services
* Experience within private healthcare or remote/digital care models
Personal Qualities:
* Demonstrates adaptability in changing environments.
* Shows assertiveness when needed.
* Possesses excellent people skills.
* Works independently and takes initiative.
* Proves to be dependable and trustworthy.
* Handles complaints with fairness and compassion.
* Maintains a pragmatic, organised, and solution-oriented mindset.
* Self-motivated and displays a strong dedication to patient safety, quality, and ongoing improvement.