Working with the Clinical Governance Manager, the post holder will support the facilitation, development, delivery and implementation of the Divisional Clinical Governance work to achieve an effective and efficient clinical governance function. The main focus will be to provide clinical input to assist the Clinical Governance Manager in implementing the governance agenda and achieving compliance with external and internal regulations.
The post holder will play a key role in supporting the integration of Clinical Governance into service delivery across the Division and will be responsible for developing clinical governance systems that gather and collate evidence to provide assurance to regulatory requirements such as CQC, NHS Resolutions, Quality Accounts and CSE.
Governance and Performance
* In conjunction with Group Managers, Group Clinical Managers and identified Leads and Champions, support the implementation of the division’s governance work programme in line with the integrated business plan and Clinical Strategy.
* Embed and monitor outcomes and standards relating to CSE, CQC and NHSLA in clinical services, ensuring identified Leads are involved on an ongoing basis.
* Support clinical services to identify and collect information on aspects of practice to evidence compliance, e.g., areas of good practice, audit and innovation.
* Liaise with appropriate clinicians and support them to ensure requests for information regarding clinical governance are returned within agreed timeframes for assurance purposes.
* Undertake impact assessments for new business and clinical processes to ensure clinical governance gaps are identified, assessed and escalated if appropriate.
* Support services in the Division to develop local clinical governance reporting structures at team level.
* Hold responsibility for clinical governance oversight of all information requests received within the division—including court orders, police requests, SARs and FOI requests—ensuring robust redaction assessments and assurance processes are undertaken in line with Information Governance legislation and organisational policy.
* Work with Group Clinical Managers, Group Managers, Clinical/Professional Leads and the Patient Experience Lead to develop information on clinical services that is current and ensures Children and Families can access information as and when required.
Risk Management
* Assist Governance lead with monitoring processes relating to incidents and complaints to ensure that agreed timescales are adhered to, action plans developed and followed up.
* Collate and analyse data from the Risk Management System (Datix) as required for performance monitoring, audit and to support service reviews.
* Co‑ordinate a programme of audit related to the risk agenda, ensuring compliance with statutory duties, quality and principles of Governance and patient safety.
* Develop an audit methodology to provide assurance that actions from PSIRF PSII or after‑action reviews have been implemented.
* Ensure that information from Datix is used to inform clinical audits and to notify possible risks to the Clinical Governance Manager for appropriate escalation.
* Take the lead on disciplinary investigations and PSIRF learning from incidents.
* Support staff with investigations arising from incidents, including information gathering and monitoring actions from recommendations.
* Ensure a system is in place to ensure risk assessments are undertaken and any action arising is implemented and monitored.
* Co‑ordinate an ongoing risk assessment work plan to ensure risk assessments are within timescales for updates.
* Co‑ordinate and prepare reports for divisional and corporate committees and inspections by external regulators and internal auditors as required.
* Identify and analyse trends from incidents for discussion at Divisional, Service and Team meetings in order to agree actions and implementation plans.
* Disseminate alerts and follow‑up responses as appropriate ensuring timescales are adhered to; support clinical services with identification of equipment and processes that may pertain to alerts.
* Maintain close links and foster good working relationships with services within the division and corporate departments as appropriate.
Clinical Audit and Effectiveness
* Work with clinicians to ensure a programme of clinical audit activity is undertaken across the Division through the annual planning process.
* Take lead responsibility for the development, review and monitoring of the Division’s Forward Audit Plan.
* Support the Divisional Clinical Effectiveness and NICE Leads in monitoring the implementation of actions arising from Audits and NICE Guidelines.
* Support the Clinical Effectiveness Lead with coordinating the Clinical Effectiveness meetings, planning and ensuring distribution of agenda and meeting papers and taking minutes.
* Support the development of annual clinical audit and effectiveness report.
* Attend meetings and represent the Division as directed by the Clinical Governance Manager (including, but not exclusive to: Risk Management, Operational Development meetings, Corporate Clinical Effectiveness Committee, Infection Control Committee and Essence of Care).
Management and Leadership Responsibilities
* Have a thorough understanding of the national perspective and future strategy for the NHS and related areas of health to ensure staff are fully aware of implications and can contribute effectively to service improvement.
* Develop and empower all members of your team to perform to high standards and innovate.
* Ensure supportive staff management arrangements are in place and carry out appraisals or personal development reviews (PDRs) for direct reports, ensuring all staff have annual PDRs with specific objectives and effective personal development plans.
* Develop staff knowledge and skills to promote equality and diversity and address inequalities in employment and service delivery; ensure specific equality objectives are included in PDRs.
* Develop a working culture that ensures Health and Wellbeing and promotes a Great Place to Work and Learning for staff.
This advert closes on Friday 12 Jun 2026.
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