Clinical Governance Manager

Mid Cheshire Hospitals NHS Foundation Trust
£41,659 to £47,672 pro rata, per annum
Closing date
11 Dec 2023

View more

Other Health Profession
Band 7
Part Time
A Clinical Governance Manager who works as part of the Clinical Governance Support Unit working closely with the Divisional Management Team to maintain and develop systems that improve the Patient Safety and the Clinical Governance agenda's e.g. Risk Management, Quality Improvement, Quality Surveillance, and Patient Safety across the Division as a whole and who assists in supporting the Divisions in achieving their required standards.

Main duties of the job

The post holder will ensure that effective systems supporting the corporate and clinical governance agenda are established, managed, evaluated and developed on behalf of the Director of Clinical Governance, delivered through clinical divisions.

The post is largely a facilitative and advisory role, so effective communication is essential, plus an ability to gain co-operation from a wide variety of professionals. The role will incorporate the promotion of a positive learning environment where changes are established and embedded to improve patient safety, experience and outcomes. An open learning culture will be fostered which ensures that both lessons are learnt and appropriate action is taken in response to mistakes and service failures.

The post holder will establish with the Divisional leads, divisional assurance arrangements to evidence compliance with the Trust patient safety framework, CQC registration requirements and Commissioner quality requirements to ensure continual review, escalation of related risks at point of emergence and effective mitigation.

With the Divisional Senior Management Team, the post holder will foster a culture, which engages clinical and non-clinical staff to deliver excellent and high-quality clinical services. The post holder will also work closely with the Legal Services Manager and Patient Experience Team, the Patient Safety Team and Clinical Audit and Effectiveness Team.

About us

Mid Cheshire Hospitals NHS Foundation Trust (MCHFT) provides good quality, safe and effective healthcare to the people of Cheshire and beyond. The Trust, which manages Leighton Hospital in Crewe, Victoria Infirmary in Northwich, and Elmhurst Intermediate Care Centre in Winsford, was established as an NHS Trust in April 1991 and became a Foundation Trust in April 2008.

We employ almost 5,000 members of staff, provide around 540 hospital beds, with a range of services including accident and emergency, maternity, outpatients, therapies, and children's health.

The Trust is also part of Central Cheshire Integrated Care Partnership (CCICP), a unique local health partnership that provides a range of community services for people across South Cheshire and Vale Royal.

During the Coronavirus pandemic, the Trust was recognised nationally for its 'Be Safe Be EquiPPEd' campaign, which aimed to make the Trust as safe as possible for staff and patients, through supporting the correct use of PPE. The results in the 2020 national NHS Staff Survey showed improvements in all elements of the safety culture theme, with 92% of respondents feeling their role made a difference to our patients. We were also recognised nationally for our workforce health and wellbeing initiatives.

At Mid Cheshire, we value our staff and appreciate that in order to give our patients the best quality, compassionate care, we also need to look after our colleagues.

Job description

Job responsibilities

Principle Duties and Responsibilities

To co-ordinate the overall day-to-day delivery and strategic development of the governance agenda (including CQC requirements and other national guidance relating to governance) and advise and develop plans for change in practice, policies and procedures as necessary. This includes the following duties:
  • To work as a key member of the Divisional Senior Management Team to ensure that robust governance arrangements are in place and governance is embedded.
  • To be responsible for providing specialist advice to the Division on the implementation of governance policies and procedures that enables the Division to strategically develop its governance management.
  • To be responsible for the design and implementation of improvements to governance processes and policies to ensure the roll out of key lessons across the Division from governance activities.
  • To investigate and analyse issues arising from all types of governance data, advise the Division on implications and actions required, and develop actions to address issues and trends in order to ensure learning and planning.
  • To constructively challenge processes and behaviours in relation to governance, risk and quality of care, escalating to direct line managers any performance issues as required.
  • To lead by personal example, to establish a high profile for governance within the Division, working with others to ensure good practice, communicate lessons learnt and celebrate success.
  • To lead on the identification of governance projects required within the Division and the successful implementation and evaluation of the projects undertaken.
  • With the Divisional Associate Medical Director, Head of Nursing, Divisional Directors, Clinical Leads and Matrons, lead the development of plans for Divisional and Directorate governance assurance, agreeing monitoring arrangements that will ensure delivery, producing reports on progress and plans to address any shortfalls. This will include compliance with CQC requirements and other regulatory requirements.
  • To be responsible for the preparation, delivery and performance monitoring of action plans, relating to Divisional governance information and documentation, ensuring it is kept up to date and available for review or accreditation as required.
  • To assist in monitoring implemented changes designed to improve an area of service, such as reviewing the processes in place to control the introduction of new interventional procedures into the Division.
  • To analyse the results of governance reviews/audits and develop actions plans that advise the Division of any remedial actions required.
  • Capture the quality of services for the division within defined reports as part of the governance meeting agenda.
  • Provide advice and support to the Division and others on all issues relating to patient safety (e.g. incidents and risk).
  • The post holder will be support the risk management processes.
  • Ensure support to the Divisions to ensure all incidents are reviewed in a timely manner.
  • To expertly lead and support other members of staff within the Division who undertake incidents and complaints investigations.
  • Support and advise the Division gaining assurance on compliance with the requirement to inform patients/relatives (Being Open/Duty of Candour).
  • When required, ensure all incident responses are fit for purpose, addressing all issues of concern raised and identify learning and actions for improvement.
  • Lead and/or support investigations as requested, ensuring the use of PSIRF tools and write the reports identifying achievable actions that transfers in to individual and organisational learning.
  • Ensure that any patient safety/quality related themes and trends are identified early, analysed and plans to mitigate are formulated and effectively shared and monitored.
  • Co-ordinate and prioritise multiple competing, high importance tasks and actions.
  • To provide regular updates on Divisional performance on governance as required.
  • To lead on the delivery of governance education by designing and providing training on key Governance topics for delivery within the Division.
  • To participate, as required, in providing education on governance across the Trust, providing an expert resource for the Trust to call upon as required.

Person Specification



  • Relevant supervisory management skills



  • Clinical Professional Qualification.



  • Knowledge of the National and local Governance agenda e.g. patient safety, clinical/general risk management, clinical governance and Health & Safety legislation
  • Experience and knowledge of current approaches to SI management, evidence and awareness of Safeguarding E Practical/Intellectual Skill
  • Knowledge of Current Professional and NHS Issues


  • Quality Improvement qualification / knowledge / experience
  • An understanding of the Quality Governance Agenda and its impact on patient centred care delivery, quality and service development
  • Excellent inter-personal and communication skills

Employer details

Employer name

Mid Cheshire Hospitals NHS Foundation Trust


Leighton Hospital

Middlewich Rd



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