About this role
Job summary
At St Lukes Hospice, we are seeking an exceptional Head of Quality to lead our governance, quality, patient safety, and continuous improvement agenda across the organisation.
This is a pivotal leadership role where you will shape and strengthen a culture of excellence, compassion, learning, and innovation ensuring our services remain safe, effective, evidence-based, and truly patient-centred.
Main duties of the job
Reporting into the senior leadership team, you will provide strategic and operational leadership across:
Clinical governance and quality assurance Patient safety and risk management CQC compliance and inspection readiness Patient experience and engagement Information governance Quality improvement and audit programmes Research, innovation, and organisational learningYou will work collaboratively with clinical and non-clinical leaders to ensure robust governance systems are embedded throughout the Hospice and aligned with the CQC Single Assessment Framework.
This is an opportunity to influence while also leading meaningful improvement initiatives that directly enhance patient and family care.
Key responsibilitiesYou will:
Participate in the senior on-call rota supporting 24/7 operations
Lead the development and delivery of the Hospice Quality Strategy
Drive continuous improvement and governance excellence across all services
Lead CQC preparation and support the organisations ambition to achieve and sustain an Outstanding rating
Oversee incident management, investigations, risk registers, and quality assurance programmes
Champion a positive culture of learning, psychological safety, and Just Culture principles
Provide expert leadership on patient safety, governance, compliance, and quality improvement methodologies
Lead on patient experience, complaints, feedback, and organisational learning
Support innovation, research activity, and evidence-based practice
About us
St Lukes Hospice cares for people approaching the end of their life in Harrow and Brent. We aim to give the people we care for the best possible quality of life, every day. Supporting local people and their families is at the heart of what we do focusing on what matters the most to them is at the centre of our care.
Founded by local communities in 1987, we have been providing free expert end of life care and support to local people both in the community and from our beautiful Kenton Grange building, surrounded by tranquil gardens.
Two thirds of our care is provided in the comfort of peoples homes, as we respect that this is where most people would like to be looked after. Our specialist community team of nurses helps people to manage more complex needs whilst our Hospice at Home team supports people to remain in their own homes by providing practical care and support.
Our inpatient unit (IPU) at Kenton Grange cares for people in their final days, providing intensive care to help get symptoms under control or give respite care. Many of the people who are cared for in our IPU go home again.
Job description Job responsibilities
Job Purpose and scope The Head of Quality will lead and deliver a robust, integrated governance and quality framework that drives continuous improvement in quality, safety, and effectiveness across the Hospice. Working closely with clinical and non-clinical leaders, the post-holder will ensure services are evidence-based, patient-centred, and compliant with all regulatory and statutory requirements. The role provides strategic and operational leadership and management across governance, quality assurance, risk management, patient experience, information governance, and continuous improvement. The post-holder will also contribute senior clinical leadership, supporting a positive culture of quality, learning, safety, and innovation. Key Responsibilities Include: Developing and implementing a comprehensive Quality Framework and strategy that aligns with regulatory requirements and industry best practices. Overseeing quality assurance programs, policy and procedures, including audits, risk management, and continuous improvement initiatives. Strengthening effective governance structures and processes to ensure compliance and accountability. Ensuring alignment of all quality systems and evidence with the CQC Single Assessment Framework, including mapping evidence to quality statements and evidence categories. Collaborating with the Senior Leadership and Executive Team to drive strategic quality objectives. Providing leadership and support to clinical staff in complying with Governance and Quality standards. Monitoring and analysing quality metrics to identify trends and areas for improvement. Leading the preparation for external regulatory inspections and audits. Fostering a culture of quality, safety, and continuous improvement throughout the organisation. Participation in an on-call rota to support effective operations 24/7 1. Main Duties & Responsibilities Governance and Risk Lead and maintain effective clinical governance systems across the organisation. Embed quality, safety, and risk management into all aspects of Hospice operations. Act as a core member of the Board-led Clinical Governance Committee, contributing papers, reports, and expert advice. Prepare and present high-quality assurance and quality reports to the Board of Trustees and Senior Leadership Team. Lead the development, delivery, and evaluation of the annual quality improvement and audit programme. Maintain oversight of the organisational risk register, ensuring risks are appropriately assessed, mitigated, monitored, and escalated. Support the Director of Infection Prevention and Control in the delivery and assurance of the infection prevention and control programme for the hospice, ensuring compliance with mandatory standards. Promote a proactive safety culture by leading and supporting investigations into serious incidents and complex concerns under PSIRF principles. Deliver analytical reports that move beyond individual blame to identify systemic learning, ensuring robust Duty of Candour and sustainable service improvements. Monitor, analyse, and report trends in incidents, accidents, near misses, and safety data, ensuring learning leads to service improvement. Support medicines management governance processes to ensure safe and effective practice. Lead the production of the annual Quality Account and attend external scrutiny meetings as required. Support delivery of annual priorities and organisation-wide improvement projects. Quality Assurance and Improvement Develop and implement a comprehensive quality strategy aligned to the Hospices mission, values, and strategic objectives. Lead preparations for CQC inspections and ensure ongoing compliance with registration requirements including continuous readiness aligned to the CQC Single Assessment Framework and quality statements.. To lead on and support preparations for inspection and review visits by external monitoring bodies including the Care Quality Commission, which will include the gathering, analysing, interpreting and presenting extensive and complex data and information. Drive progress towards achieving and sustaining an Outstanding CQC rating. Ensure implementation of national and local clinical guidance (e.g. NICE). Promote and embed quality improvement methodologies and a culture of continuous improvement and learning across all services. Lead the collection, analysis, benchmarking, and interpretation of quality and performance data, including KPIs and Hospice UK submissions ensuring insight drives decision-making, risk identification, and service improvement. Provide assurance and recommendations based on insight from quality data and patient outcomes. To represent the governance and quality agendas at external local, regional and national meetings on behalf of the hospice and communicate outcomes. Patient Experience and Engagement Lead a comprehensive patient, family, and carer experience strategy, ensuring feedback is systematically captured, triangulated with other data sources, and used to drive measurable improvements. Ensure patient experience data is integrated into governance reporting, contributing to organisational learning and CQC evidence. Ensure systems are in place for collecting, analysing, and responding to patient, family, and carer feedback. Oversee effective management of complaints, compliments, and concerns, ensuring timely responses and organisational learning. Promote meaningful involvement of patients and families in service improvement and quality initiatives. Research and Innovation Lead the development of a research-active culture within the Hospice. Support research activity including journal clubs, poster presentations, external research collaborations, and internal project delivery. Strengthen the organisations capacity and governance for research and innovation. Information Governance Provide clinical oversight for information governance arrangements. Oversee effective use, development, and clinical integrity of the EMIS clinical database with the support of the informatics team. Ensure appropriate management of Data Subject Access Requests. Leadership and Management Contribute to the development and delivery of the Hospices clinical strategy, ensuring quality and governance are central. Foster positive, collaborative relationships internally and externally. Provide leadership, direction, and support to Patient engagement, Informatics, Risk and Compliance & Administration teams. Ensure effective people management, including recruitment, supervision, appraisals, and performance management. Manage departmental budgets and resources effectively. Maintain professional registration, CPD, and revalidation requirements. Undertake additional responsibilities aligned with skills and organisational need. Ensure alignment between quality governance and workforce governance, including oversight of training compliance, safe staffing risks, and workforce-related quality indicators. Promote a culture of continuous learning, psychological safety, and high performance across teams. Promote a Just Culture and Freedom to Speak Up environment, ensuring staff feel safe to raise concerns and that learning is embedded across the organisation. Participate in the senior on-call rota as required to support 24/7 operations.
Person Specification
Qualifications Essential
Registered with relevant professional body either Nursing and Midwifery Council (NMC) or Health and Care Professions Council (HCPC) Educated to degree level Masters Degree or equivalent experience that can be evidenced Evidence of continued professional development Extensive knowledge of clinical governance process and procedures including risk management Knowledge of CQC Key lines of enquiry, patient safety initiatives and monitoring matrix, KPIs and benchmarking
Desirable
Significant experience in a senior quality management role within a healthcare setting. Proven track record of leading quality improvement initiatives and achieving measurable outcomes. Experience in managing compliance with healthcare regulations and standards, particularly CQC. Experience in staff management and development. Understanding of the current issues pertaining to specialist palliative care IOSH trained
Experience Essential
Understanding and experience of CQC inspections Understanding and experience of user engagement strategies Policy development Analysis and presentation of data Experience of leading and conducting investigations Delivering QIP projects and clinical service improvement projects using quality improvement methodologies In-depth knowledge of quality assurance methodologies, clinical governance, and regulatory requirements in healthcare. Strong analytical and problem-solving skills, with the ability to interpret complex data and drive decision-making.
Desirable
Research Database management
Skills / Personal Attributes Essential
Commitment to the mission and values of St Lukes Hospice. Compassionate approach to patient care. High level of integrity and professionalism. Resilient and adaptable, with the ability to thrive in a dynamic and challenging environment. Proactive and innovative, with a passion for continuous improvement. Excellent leadership and people management skills, with the ability to inspire and motivate teams. Exceptional communication skills, both written and verbal, with the ability to influence at all levels. Ability to manage interruptions and priorities Ability to manage sensitive and difficult situations e.g., complaints Experience of leading and influencing change
Desirable
Proficiency in the use of quality management software and tools.
Disclosure and Barring Service Check This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.
UK Registration
Applicants must have current UK professional registration. For further information please see NHS Careers website (opens in a new window).
Employer details Employer name St Luke's Hospice
Address Kenton Grange
Kenton Road
Harrow
Middlesex
HA3 0YG
United Kingdom
Employer's website https://www.stlukes-hospice.org/join-our-team/current-vacancies/ (Opens in a new tab)