About this role
Job summary
This is an exciting opportunity for you to join Willow Wood Hospice, working closely with the Head of People.
Main duties of the job
You will lead the Hospices quality governance, assurance and compliance activity ensuring robust systems for audit delivery, regulatory and commissioner readiness, policy/document control, risk and incident governance and performance assurance reporting. This role ensures that our governance systems uphold the Hospice philosophy of compassionate, safe and person centred palliative care.
The postholder will ensure evidence based compliance and CQC aligned expectations supporting safe, effective and well-led care.
About us
Willow Wood Hospice is an adult Hospice providing specialist palliative care for patients with life limiting illnesses, both cancer and non-cancer diagnosis. We provide care, free of charge, and patients, families and their carers are at the centre of everything we do.
Willow Wood Hospice is a registered charity, not part of the NHS and it costs over £4.1 million to run the Hospice every year.
Job description Job responsibilities
Governance, assurance and regulatory compliance
Lead day-to-day delivery of quality governance systems, ensuring structured oversight of compliance requirements, evidence collation and reporting cycles across services.
Maintain organisational readiness for external scrutiny by ensuring governance artefacts are current, complete, traceable and accessible.
Support the CEO & Senior Management Team (SMT) with assurance reporting, action tracking and governance development activity.
Support the Clinical Director and all Hospice teams in meeting regulatory responsibilities.
Embed Hospice values into governance processes, ensuring compassionate practice is reflected in all assurance activity.
External inspection and accreditation readiness
Coordinate preparation and evidence portfolios for external inspection and accreditation activity e.g. CQC and other relevant framework standards as applicable.
Monitor and collate the outcome of any CQC visits, formulating in collaboration with other key people any action plans, ensuring completion of any agreed actions.
Work with departmental heads to ensure compliance with regulatory standards and to ensure that there is up to date evidence in place to ensure compliance with the regulatory standards.
Maintain inspection readiness trackers, action logs and evidence sets, ensuring timely closure of action with clear audit trails.
Support CEO and SMT during visits/reviews including briefings, evidence retrieval and follow-up action coordination.
Support teams to understand how regulatory standards apply within a Hospice context.
Audit programme and quality improvement
Lead and deliver the internal audit programme across the Hospice, ensuing audits are scoped, scheduled and completed to deadline using standardised tools/templates.
Ensure audits capture the full breadth of Hospice care, including patient experience, family support and holistic wellbeing.
Ensure audit findings translate into SMART actions, tracked to completion with evidence based closure and measurable improvement.
Lead continuous improvement by promoting learning, standardisation and effective governance routines across teams.
Risks, incident, complaints and learning
Lead effective incident, complaint and feedback governance, including logging oversight, investigation support, thematic reviews and tracking learning/actions to closure.
Lead on the Risk module on Vantage
Contribute to risk management processes (risk registers, risk assessments), ensuring mitigation actions are tracked and evidenced.
Promote a just culture and leaning approach to safety and quality improvement.
Ensure that learning from incidents and feedback is shared sensitively and constructively, recognising the emotional nature of Hospice work.
Training, engagement and stakeholder working
Build effective working relationships with the Senior Management Team, clinical leads, operational managers and wider staff groups to enable sustained compliance.
Represent the Quality & Governance functions at internal meetings and where appropriate, external stakeholder discussions.
Professional and organisational responsibilities
Maintain confidentiality and comply with information governance requirements, GDPR and organisational IG policies, ensuring secure handling and appropriate access controls for governance evidence.
Maintain up to date knowledge of relevant quality, governance and assurance frameworks applicable to the Hospice.
Take responsibility for the management, development and improvement of systems supporting your role e.g. Vantage modules or other systems as required.
Undertake other duties consistent with the post as required to support organisational priorities.
Become an active member and participant in any Hospice UK quality initiatives / groups.
Network with similar post holders both regionally and nationally in order to support benchmarking for Willow Wood Hospice Services and also keep up to date with quality agenda in healthcare.
To adhere to all Willow Wood Hospice standards, policies and procedures.
To take responsibility for own personal learning and development, and to support the learning and development of others and the organisation as a whole; a commitment to completing all training required and refreshing training as appropriate.
To conduct all work in a manner reflective of the organisational values and behaviours.
Person Specification
Qualifications Essential
Degree or equivalent experience/qualification. Evidence of continued professional development.
Desirable
Clinical or Risk Management Qualification. Professional qualifications in management, quality, project management or governance. Root cause analysis/serious incident training / qualification.
Personal Attributes and qualities Essential
A naturally collaborative team player. High personal integrity and commitment. Empathy with the aims and values of the Hospice. An understanding of corporate responsibilities. Ability to work under pressure. Proven track record at managing resources effectively. Demonstration of strong assertiveness and interpersonal skills. Demonstrate flexibility both within the Hospice and across organisational boundaries with credibility and integrity.
Experience Essential
Experience working within a healthcare or social care setting. An understanding of the General Data Protection Regulation and the importance of confidentiality. An understanding of the meaning of and responsibility for Safeguarding. Experience working in a quality/compliance role. Proven track record of planning and facilitating service change in response to risk management issues. Ability to produce high quality comprehensive reports to senior management level. Ability to analyse and condense highly complex information to produce concise briefings and summaries. Ability to interpret and apply national and local policy. Excellent communication, negotiating, influencing, organisation and interpersonal analytical, interpretive and conflict management skills. Good presentation skills and the ability to present complex and sensitive information to senior managers where there may be barriers to acceptance. Ability to communicate complex governance information with compassion and clarity. Practical experience of quality and governance principles, systems and processes. Detailed knowledge of risk management, clinical and corporate governance and its impact on the organisation. Knowledge of computer skills for use of power point presentations, reports statistical analysis e.g. PowerPoint, excel and work programmes.
Desirable
Knowledge and experience in clinical audit. Evidence of collaborative working across a wider health/social care economy. NHS Standards Framework. Vantage (Sentinel) risk management software (or equivalent e.g. Datix, Ulysses Safeguard). Evidence of carrying out complex investigations RCA, serious incidents, division reviews etc. Evidence of collaborative working across a wider health/social care economy. Good working knowledge of the national agenda around health reforms. Good understanding of the key national initiatives/Trust priorities around: - oPatient safety. oNPSA, MHRA & CQC. oDuty of Candour. oSerious incident and complaints management.
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.
Employer details Employer name Willow Wood Hospice
Address Willow Wood Close
Ashton under Lyne
Lancashire
OL6 6SL
United Kingdom
Employer's website https://www.willowwood.info/ (Opens in a new tab)