This job has expired

Divisional Governance and Quality Manager

Dorset County Hospital NHS Foundation Trust
£35,392 to £42,618 Per Annum
Closing date
30 Nov 2023

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Other Health Profession
Band 6
Contract Type
Full Time
An exciting opportunity has arisen for a Divisional Governance and Quality Manager in the Urgent and Integrated Care Division.

The Division comprises of Vascular and Metabolic Care, Integrated and Holistic Care, Unscheduled Care, and Clinical Support Services.

Applicants will be expected to work with a wide variety of health care professionals across the division and wider trust, be enthusiastic, motivated and with a passion for service development.

Main duties of the job

The post holder will lead the Division in all aspects of incident, risk management, and complaint activities as part of the Division's implementation of Governance and quality and to ensure the Division meets its obligations in relation to Trust local and national standards (e.g., relevant standards appertaining to Care Quality Commission Standards, the NHSE Patient Safety Incident Response Framework etc.).

The post holder will be delegated a high level of responsibility to manage their own work and they will be expected to use their own initiative, taking key decisions within broadly defined parameters.

About us

At Dorset County Hospital (DCH) we aspire to providing outstanding care for people in ways which matter to them. Our trust strategy is focussed on three strategic goals: People, Place, and Partnership. It signals our intention to truly value our staff. Our people are our most important asset, and we want them to feel valued, welcomed, respected, they belong and matter. We recognise the link between high levels of staff satisfaction and improving patient experience and outcomes.

We are a Trust that celebrates diversity, and we are committed to creating an inclusive environment for all employees. Dorset County Hospital has a number of employees from overseas delivering high quality services and we recognise the value of diversity in leadership.

Job description

Job responsibilities

The main purposes of the post are:To be responsible for co-ordinating risks, incidents and complaints for the Division and point of contact for staff regarding risks, incidents and complaints involving specialities/departments within the division.To participate and support in the development of clear and robust clinical governance arrangements within the Division and Care Groups.To receive both written and verbal complaints made to the Division/Trust.

To collate the responses received from parties involved in the complaint. To assist in the gathering of information to use for patient feedback and learning points to improve and enhance the quality of service provided by the Trust.To provide co-ordination and to be a resource sharing in depth knowledge within/for the Division for clinical governance issues. Prompt escalation is necessary for Serious Incidents never events high and extreme risks possible compensation claims and breach of confidentiality.To support the Division by producing high level quality performance reports which will involve and include data analysis and narrative. The post holder will be attending, participating and present at: Divisional Business & Governance Meeting. The post holder will observe Divisional Performance Meetings, and Quality Committee to support the Divisional Head of Nursing & Quality.Deputise for the Divisional Head of Nursing & Quality and Matrons at quality meetings as and when required.To lead the Divisional Complaints, Risks and Actions Group (CRAG) including creating agenda and collating papers, generate reports, and record updates on the action log and Datix Risk Management System.Co-ordinate and act as a main point of contact for the Division for CQC inspection process and follow this up with outcomes and actions to address any gaps in compliance across the Division on an ongoing and continuous basis. Ensure that all services are aware of and monitor compliance against the CQC standards and Trust action plan.To request and collate monthly Clinic Typing Turnaround Times from all Specialties within the Division to report to the Divisional Manager.To be a part of the National Safety Standards for Invasive Procedures (NatSSIPs) working group to implement the Universal Safety Checklist for Interventional Procedures.Support the Division to identify and analyse trends, themes and learning from incidents and serious incidents and ensure there are processes in place for sharing these widely across the Division to support service improvements and reductions in harm.To set up Divisional Learning from Incidents Panels and Divisional Assurance Panels as and when required, ensuring that attendees required can attend and the agenda and papers are provided before the meeting.To monitor the Care Group and Divisional Risk Registers on Datix ensuring they are up to date and actions are being completed in a timely manner.Monitor the CQC action plan for updates and chase when actions are overdue. Attend the monthly CQC Inspection Steering Group, when required, to provide updates from the Division and bring back actions. To support the collecting and sign off process of information for CQC visits.Attend Hospital Mortality Group, providing monthly updates (if required) and producing the quarterly mortality report for the Division every quarter.Maintain and updated the Mortality spreadsheet daily for recent deaths within the Division. Request notes for deceased patients once released from the Mortuary/Clinical Coding and follow the Divisional Mortality SJR process for ensuring the completion of SJRs in a timely manner.Liaise with the Divisional Governance and Quality Manager from Family and Surgical Services Division to complete the Quarterly NHSI Mortality Data submission at the end of each quarter.Ensure that support, advice and training is provided locally on clinical audit in line with the Trust wide clinical audit strategy and mandatory audit requirements/ NICE Guidance.Provide training for all levels of staff on Datix for complaints, incidents and risk registers when required.

Person Specification

Education, Qualifications and Training


  • Educated to post graduate diploma level or equivalent relevant experience
  • Training relating to quality improvement and quality assurance methodologies for example QSIR, QI lite.

Knowledge and Experience


  • Expert knowledge and experience in using Risk Management systems and processes for managing and reporting, e.g. Incidents, investigations, complaints, claims and risk register modules
  • Significant & recent experience of working at a similar level within a healthcare setting, in a hands on operational role
  • Experience and evidence of presenting to senior members of a clinical and management team
  • Previous negotiating experience essential
  • Recent experience of working with the Trust's PAS system, DATIX and BI is essential


  • Significant and considerable administration experience including complex report writing
  • Significant experience of working with Microsoft Excel and Word

Skills and Abilities


  • The ability to communicate effectively with all members of a multi-disciplinary team
  • Ability to work on your own initiative and make informed decisions
  • Ability to work independently and provide high-level presentation material for performance/quality related projects
  • A high level of accuracy and attention to detail coupled with the ability to work to deadlines
  • Excellent organisation skills and the ability to plan ahead


  • An understanding of the need for patient & staff confidentiality
  • Fast and accurate keyboard skills and the ability to use e-mail
  • Understanding of governance and risk issues in an NHS setting.
  • Experience in a customer service setting either within or outside the NHS or other healthcare environment.

Employer details

Employer name

Dorset County Hospital NHS Foundation Trust


Dorset County Hospital

Williams Avenue



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