Governance Manager

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Job summary

The post holder will ensure that the SELDOC Group (which includes Verve Healthcare) has innovative and robust clinical governance systems to support the delivery of high patient quality care. This will include developing, implementing and maintaining effective patient participation strategies, providing effective and efficient handling of incident reporting systems and complaints that comply with the NHS and best practice standards. The successful applicant will develop the Patient and Public information and clinical governance systems to ensure Care Quality Commission (CQC) registration is maintained. The post holder will also provide administrative support to the Clinical Governance Committee to develop policies, maintain clinical databases, conduct quality audits and deliver against the annual operating plan. The post holder will be a member of the Clinical Governance Team.

Main duties of the job

Key duties and responsibilities

Maximise the opportunities for patient response/feedback and develop processes that support this.

To develop and lead on a process that allows the organisation to engage and work with users or potential users of the services in the development of future services.

Develop a repository of patient information media to support effective communication with patients about health, self-care and appropriate access to services.

To establish and maintain an effective process for obtaining patient feedback in line with commissioning and National quality requirements.

To lead in the investigation and handling of complaints.

To work closely with the Group Medical Director, their deputies and the management team to agree and enable regular quality audit process. t

To review complaints, incidents, feedback, results of quality audit and provide feedback to relevant staff on their performance.

To be responsible for medical records management, in accordance with Caldicott principles and information governance processes.

To review and develop policies

To produce the Clinical Governance reports.

To arrange resuscitation training and maintain a database of staff who have attended training.

To work as part of the day time management team to ensure a positive and productive team environment is developed and maintained at all times.

About us

SELDOC Healthcare provides urgent care in South London. This is a really exciting time to be joining us as we diversify to maximise opportunities from the changing NHS landscape. We are and always will be a "patient-first" organisation, working well as a team to look out for our patients and to look out for each other. If you join us, there will be plenty of opportunity for you to make your mark. You will receive support that is second to none, a real opportunity to lead, and the chance to shine, working with colleagues who care about you. We have a good reputation for delivering good healthcare, for mobilising well and for being easy to do business with. We would love you to join us.

Job description

Job responsibilities

Job description

Job title: Governance Manager

Base: Remote working but may be requires to attend site

Accountable to: Associate Clinicial Director

Hours: 22.5 hr per week, 3 days

Salary: £21,600 p.a.

Key working relationships: GroupMedical Director, Associate Clinicial Director, Quality Manager, Senior Management Team, Operations team, HR, Finance.

Job summary

Key duties and responsibilities

Patient and Public Participation

Maximise the opportunities for patient response/feedback and develop processes that support this.

To develop and lead on a process that allows the organisation to engage and work with users or potential users of the services in the development of future services.

Work with local focus groups to enhance SELDOCs profile and understand the expectations of stakeholders.

Develop a repository of patient information media to support effective communication with patients about health, self-care and appropriate access to services, for example, improve information for patients on when and how to use services.

Link with GP practice Members to identify how to best meet the needs of their practice populations.

Complaints and significant incidents management

To establish and maintain an effective process for obtaining patient feedback in line with commissioning and National quality requirements and to contribute towards overall improvement of services.
To provide expert liaison and correspondence with patients, relatives and their representatives.

To lead in the investigation and handling of complaints received ensuring that these are entered into a database and handled in accordance with the complaints procedure within agreed timescales.

To prepare and issue timely, accurate, professional and sensitive correspondence in response to complaints.

To maintain an effective database of all complaints, feedback and incidents, flagging SIs, undertaking communication of actions and lessons learned.
Work with the Group Medical Directors and their deputies to undertake Root Cause Analysis.
To produce the Clinical Governance reports, Commissioners reports and Annual report for the Clinical Governance and Operations Committees. This should include details of all Clinical Governance activities including complaints, incidents, SIs, quality audit, patient engagement, safeguarding, medicines management and performance against NQRs. The reports should also include proposed actions and feedback on progress.
To develop an effective method of feedback on compliments and complaints for clinical and operational staff that enables learning across the organisation.
To provide other ad hoc reports as required for the Medical/Clinical Directors, CEO, Board and commissioners.

Performance Management

To work closely with the Group Medical Director, their deputies and the management team to agree and enable regular quality audit process to ensure SELDOC provides a high quality service, meets the requirements of commissioners, quality standards (NQRs) and the CQC.

To improve and implement a robust and useful system of regular feedback to staff on productivity and quality of their performance.

To work in conjunction with the management team to implement and review performance management systems across the organisation.

To review complaints, incidents, feedback, results of quality audit and provide feedback to relevant staff on their performance.

To make recommendations for further training where this need is identified from the review process.

Medical Records Management

To be responsible for medical records management, in accordance with Caldicott principles and information governance processes, including secure call sheet storage, patients notes, patients notes reviews, access to patients records.

Database Management

To be responsible for database management by overseeing and ensuring:

Patients notes reviews, including duplicated information/amalgamation.

That all users are adhering to the requirements of summary care records, end of life care and special notes handling systems.

Providing supervision, monitoring and assistance in the uploading of data such as the safeguarding database, special patient notes, as required.

Uploading and maintaining any other patient information sharing system working collaboratively with service users and stakeholders to ensure that patients information is shared appropriately and according to IG principles.

Checking Smartcard data.

Ensure safe storage and disposal of patients records in line with NHS guidance.

To maintain a database of all safety Alerts, ensuring onward communication of information received to clinicians and operational staff, operations team, medical/clinical director as appropriate.

To maintain clinician databases which will include performance data, relevant documents and correspondence.

Policy development and maintenance

To review and develop policies as required by the clinical governance committee to meet the needs of the service and requirements of CQC.

To support the Medical Director and their deputies in preparing policies relating to clinical governance work streams.

Quality Reporting

To produce the Clinical Governance reports, Commissioners reports and Annual report for the Clinical Governance Team and Quality Committee. This should include details of all Clinical Governance activities including complaints, incidents, SIs, quality audit, patient engagement, safeguarding, medicines management and performance against NQRs. The reports should also include proposed actions and feedback on progress.

To provide performance reports for GPs and any other front-line staff.

To produce board and committee reports in accordance with meetings timetable.

To produce reports for commissioners in accordance with commissioners meetings timetable.

To produce any additional reports required for the purpose of quality and patient safety.

Training & Educational meetings

To arrange resuscitation training and maintain a database of staff who have attended training.

To coordinate and implement any new training programmes as agreed with the Medical Director or duputies.

To undertake training of operational staff and clinicians as agreed with the Medical Director or deputies.

To be responsible for coordinating and contributing to the clinical newsletter ensuring regular production according to timelines agreed with the Medical Director and clinical governance team.

New Business Opportunities

To assist, as required with the co-ordination of developing new business and contracts including the production of PQQs, tender submissions and business cases, ensuring that deadlines for submission are met.

To provide support for projects as directed by the Group Medical Director and duputies.

Corporate responsibilities

To work as part of the day time management team to ensure a positive and productive team environment is developed and maintained at all times.
To attend internal and external meetings as requested.
To produce written and verbal reports with appropriate data to support such meetings.
To support colleagues in ensuring operational and management cover is available. across all work streams.
To work in line with SELDOC values

Objectives and Personal Development

Agree annual objectives and review progress during the year with the Associate Clinicial Director

Agree a PDP with the Associate Clinicial Director

Other duties

Provide cover for the Quality Manager and other Quality Administrators when they are on leave.
Any other duties, as agreed, to meet the needs of the organisation.
The role may span across services operated by both SELDOC Ltd, and SELDOC Healthcare services.

This job description is not definitive or restrictive in any way. It will be regularly reviewed and may be amended in the light of changing circumstances following consultation with the post holder.

Job description
Job responsibilities

Job description

Job title: Governance Manager

Base: Remote working but may be requires to attend site

Accountable to: Associate Clinicial Director

Hours: 22.5 hr per week, 3 days

Salary: £21,600 p.a.

Key working relationships: GroupMedical Director, Associate Clinicial Director, Quality Manager, Senior Management Team, Operations team, HR, Finance.

Job summary

Key duties and responsibilities

Patient and Public Participation

Maximise the opportunities for patient response/feedback and develop processes that support this.

To develop and lead on a process that allows the organisation to engage and work with users or potential users of the services in the development of future services.

Work with local focus groups to enhance SELDOCs profile and understand the expectations of stakeholders.

Link with GP practice Members to identify how to best meet the needs of their practice populations.

Complaints and significant incidents management

To establish and maintain an effective process for obtaining patient feedback in line with commissioning and National quality requirements and to contribute towards overall improvement of services.
To provide expert liaison and correspondence with patients, relatives and their representatives.

To lead in the investigation and handling of complaints received ensuring that these are entered into a database and handled in accordance with the complaints procedure within agreed timescales.

To prepare and issue timely, accurate, professional and sensitive correspondence in response to complaints.

To maintain an effective database of all complaints, feedback and incidents, flagging SIs, undertaking communication of actions and lessons learned.
Work with the Group Medical Directors and their deputies to undertake Root Cause Analysis.
To produce the Clinical Governance reports, Commissioners reports and Annual report for the Clinical Governance and Operations Committees. This should include details of all Clinical Governance activities including complaints, incidents, SIs, quality audit, patient engagement, safeguarding, medicines management and performance against NQRs. The reports should also include proposed actions and feedback on progress.
To develop an effective method of feedback on compliments and complaints for clinical and operational staff that enables learning across the organisation.
To provide other ad hoc reports as required for the Medical/Clinical Directors, CEO, Board and commissioners.

Performance Management

To improve and implement a robust and useful system of regular feedback to staff on productivity and quality of their performance.

To work in conjunction with the management team to implement and review performance management systems across the organisation.

To review complaints, incidents, feedback, results of quality audit and provide feedback to relevant staff on their performance.

To make recommendations for further training where this need is identified from the review process.

Medical Records Management

Database Management

To be responsible for database management by overseeing and ensuring:

Patients notes reviews, including duplicated information/amalgamation.

That all users are adhering to the requirements of summary care records, end of life care and special notes handling systems.

Providing supervision, monitoring and assistance in the uploading of data such as the safeguarding database, special patient notes, as required.

Checking Smartcard data.

Ensure safe storage and disposal of patients records in line with NHS guidance.

To maintain a database of all safety Alerts, ensuring onward communication of information received to clinicians and operational staff, operations team, medical/clinical director as appropriate.

To maintain clinician databases which will include performance data, relevant documents and correspondence.

Policy development and maintenance

To review and develop policies as required by the clinical governance committee to meet the needs of the service and requirements of CQC.

To support the Medical Director and their deputies in preparing policies relating to clinical governance work streams.

Quality Reporting

To produce the Clinical Governance reports, Commissioners reports and Annual report for the Clinical Governance Team and Quality Committee. This should include details of all Clinical Governance activities including complaints, incidents, SIs, quality audit, patient engagement, safeguarding, medicines management and performance against NQRs. The reports should also include proposed actions and feedback on progress.

To provide performance reports for GPs and any other front-line staff.

To produce board and committee reports in accordance with meetings timetable.

To produce reports for commissioners in accordance with commissioners meetings timetable.

To produce any additional reports required for the purpose of quality and patient safety.

Training & Educational meetings

To arrange resuscitation training and maintain a database of staff who have attended training.

To coordinate and implement any new training programmes as agreed with the Medical Director or duputies.

To undertake training of operational staff and clinicians as agreed with the Medical Director or deputies.

To be responsible for coordinating and contributing to the clinical newsletter ensuring regular production according to timelines agreed with the Medical Director and clinical governance team.

New Business Opportunities

To provide support for projects as directed by the Group Medical Director and duputies.

Corporate responsibilities

To work as part of the day time management team to ensure a positive and productive team environment is developed and maintained at all times.
To attend internal and external meetings as requested.
To produce written and verbal reports with appropriate data to support such meetings.
To support colleagues in ensuring operational and management cover is available. across all work streams.
To work in line with SELDOC values

Objectives and Personal Development

Agree annual objectives and review progress during the year with the Associate Clinicial Director

Agree a PDP with the Associate Clinicial Director

Other duties

Provide cover for the Quality Manager and other Quality Administrators when they are on leave.
Any other duties, as agreed, to meet the needs of the organisation.
The role may span across services operated by both SELDOC Ltd, and SELDOC Healthcare services.

This job description is not definitive or restrictive in any way. It will be regularly reviewed and may be amended in the light of changing circumstances following consultation with the post holder.

Person Specification

Qualifications

Essential

Educated to degree level or equivalent

Desirable

Clinical background or registered healthcare professional
Evidence of Information Governance training (within last year)
Project management qualification
Postgraduate qualification in management or leadership

Experience

Essential

Experience of working in an organisation or team with a strong patient-centred focus
In depth knowledge of NHS complaints handling procedure, Clinical Governance frameworks, legislative frameworks, relevant patient safety guidance and frameworks, NQRs
Experience of successfully and proactively handling sensitive and difficult situations
Experience of managing projects and coordinating multiple work streams under tight deadlines
Experience of working with IT databases and systems, and in using Microsoft Office to produce reports and presentations

Desirable

Significant and proven experience of leading a complaints department
Significant and proven experience of Patient Engagement in a with the ability to demonstrate a thorough and tested knowledge of the requisite legislation
Experience in conducting root cause analysis (RCA)
Training in RCA
Significant knowledge of methods, systems and processes for obtaining patient feedback
Experience of policy and procedure information, implementation and monitoring
Quality improvement experience or expertise
Experience in working in OOH
Experience as a line manager
Experience of being a mentor or coach
Experience in communications and media
Proven ability to deliver national, local and organizational targets and performance measures
Experience of working on health projects with a joint provider and developing partnerships with other organizations
Experience of leading a team through organisational change
Experience of preparing bids for healthcare service contracts
Experience of developing new services, or innovative solutions to service delivery
Experience of managing a staff training programme
Experience of being a budget holder, and delivery of services within budget
Proven experience of championing patient feedback and learning from incidents and complaints throughout the organisation
Proven experience of responding to complainants and staff in a sensitive and understanding manner that demonstrates empathy

Qualities and Skills

Essential

Excellent verbal & written communication
Excellent IT literacy, organisation skills, presentation skills, including ability to manage of group/team meetings effectively
Evidence of commitment in face of challenges
Understanding of the meaning of equality and diversity within the workplace
Ability to work with complex and difficult to resolve situations, and work with a variety of interpersonal styles
Strong negotiation and influencing skills with ability to motivate and engage individuals and teams
Proven ability to gather, analyse, interpret and prepare concise reports on complex data and to be able to use such data to assess performance, identify trends and themes and provide suggestions for service improvement
Ability to build strong working relationships across a complex range of services and functions, with clinical and non-clinical staff, as well as with external stakeholders
Build and maintain constructive relationships based on shared understanding of issues with colleagues, partners and stakeholders
Demonstrate a high level of work organisation, self-motivation, drive and outcomes focus
Passionate, positive and enthusiastic about delivering high quality care for patients
Ability to be discrete and recognise the sensitivity of the work required
Willing to increase knowledge and skills in Clinical Governance, Quality and patient safety that will add a positive contribution to the department and organisation

Person Specification
Qualifications

Essential

Educated to degree level or equivalent

Desirable

Clinical background or registered healthcare professional
Evidence of Information Governance training (within last year)
Project management qualification
Postgraduate qualification in management or leadership

Experience

Essential

Experience of working in an organisation or team with a strong patient-centred focus
In depth knowledge of NHS complaints handling procedure, Clinical Governance frameworks, legislative frameworks, relevant patient safety guidance and frameworks, NQRs
Experience of successfully and proactively handling sensitive and difficult situations
Experience of managing projects and coordinating multiple work streams under tight deadlines
Experience of working with IT databases and systems, and in using Microsoft Office to produce reports and presentations

Desirable

Significant and proven experience of leading a complaints department
Significant and proven experience of Patient Engagement in a with the ability to demonstrate a thorough and tested knowledge of the requisite legislation
Experience in conducting root cause analysis (RCA)
Training in RCA
Significant knowledge of methods, systems and processes for obtaining patient feedback
Experience of policy and procedure information, implementation and monitoring
Quality improvement experience or expertise
Experience in working in OOH
Experience as a line manager
Experience of being a mentor or coach
Experience in communications and media
Proven ability to deliver national, local and organizational targets and performance measures
Experience of working on health projects with a joint provider and developing partnerships with other organizations
Experience of leading a team through organisational change
Experience of preparing bids for healthcare service contracts
Experience of developing new services, or innovative solutions to service delivery
Experience of managing a staff training programme
Experience of being a budget holder, and delivery of services within budget
Proven experience of championing patient feedback and learning from incidents and complaints throughout the organisation
Proven experience of responding to complainants and staff in a sensitive and understanding manner that demonstrates empathy

Qualities and Skills

Essential

Excellent verbal & written communication
Excellent IT literacy, organisation skills, presentation skills, including ability to manage of group/team meetings effectively
Evidence of commitment in face of challenges
Understanding of the meaning of equality and diversity within the workplace
Ability to work with complex and difficult to resolve situations, and work with a variety of interpersonal styles
Strong negotiation and influencing skills with ability to motivate and engage individuals and teams
Proven ability to gather, analyse, interpret and prepare concise reports on complex data and to be able to use such data to assess performance, identify trends and themes and provide suggestions for service improvement
Ability to build strong working relationships across a complex range of services and functions, with clinical and non-clinical staff, as well as with external stakeholders
Build and maintain constructive relationships based on shared understanding of issues with colleagues, partners and stakeholders
Demonstrate a high level of work organisation, self-motivation, drive and outcomes focus
Passionate, positive and enthusiastic about delivering high quality care for patients
Ability to be discrete and recognise the sensitivity of the work required
Willing to increase knowledge and skills in Clinical Governance, Quality and patient safety that will add a positive contribution to the department and organisation

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

SELDOC Healthcare
Address

76 Coombe Road

Kingston Upon Thames

Surrey

KT2 7AZ

Employer's website

Governance Manager

Governance Manager

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