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Clinical Governance Officer

South London & Maudsley NHS Foundation Trust
£42,471 to £50,364 per annum Inc
Closing date
5 Dec 2023

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Other Health Profession
Band 6
Contract Type
Full Time
About the team:

The Governance team works closely with the Head of Nursing and Matrons to provide assurance around patient safety issues, managing and learning from serious incidents and complaints, providing data to support services, developing systems to improve standardisation across services and embedding learning within the Directorate. We are, and serve, a diverse community and actively support and value equality and diversity within our staff.

About the role:

We are looking to recruit a highly motivated person to join our Governance team in PMOA Operational Directorate.

You will need to be able to prioritise your own work-load, managing multiple projects simultaneously and will need to be flexible and responsive to the changing needs of the services we serve. Therefore, we are looking for some-one who is efficient, friendly and organised with excellent written and oral communication skills, with the ability to analyse complex and sensitive information, who will be able to engage with all staff working across the Trust.

The ability to identify and establish credibility and good working relationships with representatives of external agencies and partners, and manage those relationships with sensitivity will be key. You will need good negotiation and influencing skills in order to achieve objectives without direct line management and the ability to work autonomously.

Main duties of the job

1. To be a key expert to the PMOA Directorate with regard to the governance and quality agenda

2. To be a point of contact for the PMOA Directorate Executive and Head of Nursing and Quality.

3. To provide comprehensive and expert leadership in relation to the facilitation and management of Datix, Complaints and Serious Incidents within the PMOA Directorate, including learning from Serious Incidents and Complaints.

4. To provide comprehensive project support and facilitation to a wide range of quality improvement, PEDIC, clinical effectiveness, clinical governance and clinical audit activities at PMOA Directorate Level.

5. The post holder will provide comprehensive support to the PMOA Directorate Governance Committees and Serious Incident

6. The post holder will co-ordinate the clinical governance agendas on behalf of the Head of Nursing and Quality.

About us

We are committed to ensuring our staff get the most out of their benefits package and understand the importance of a healthy work life balance. There is an extensive range of excellent benefits for you and your family. We want you to feel like you are part of a close knit team at SLaM. It's important to us that you are valued and appreciated and that is why we have a comprehensive benefits package on offer.

Some of our benefits are highlighted here:
  • Generous pay, pensions and leave,we offer a comprehensive pay, pensions and leave package which is dependent on the role and length of service.
  • Work life balance,flexible working and support a range of flexible options, such as: part-time working and job sharing.
  • Career development,There are plenty of opportunities to progress your career and we support your development through a number of programmes such as mentoring, coaching, positive people management, collective leadership and other talent programmes
  • Car lease,our staff benefits from competitive deals to lease cars
  • Accommodation,our staff benefits from keyworker housing available which is available on selected sites
  • NHS discounts,with discounts up to 10% from a variety of well-known retail brands though Health Service Discounts website.

Other benefits include:
  • Counselling services
  • Wellbeing events
  • Long service awards
  • Cycle to work scheme
  • Season ticket loan
  • Childcare vouchers
  • Staff restaurants

We look forward to receiving your application.

Job description

Job responsibilities

  • Quality and Governance
    • Coordinate the agenda setting for the Operations Directorate for meetings with focus Clinical Governance Committee and Clinical Effectiveness Group with the Associate Medical Director.
    • Collaborate with them in providing data for Operations Directorate quality
    • Work with them in monitoring the Operations Directorate clinical risk register, CQC Standards, NICE Guidelines, and other performance targets as required and to assist in ensuring the Operations Directorate has supporting evidence for targets.
    • Work with the Associate Medical Director to manage the evidencing of compliance with NICE Guidelines in the Operations Directorate and report to the Trust on behalf of the Operations Directorate.
    • To Line Manage governance administrator post holder to ensure the Operations Directorate responds in a responsive and compassionate manner to all complaints and compliments and information pertaining to complaints is maintained on Datix system
    • To promote the clinical governance work of the Operations Directorate and SLaM and facilitate shared learning by engaging with Operations Directorate colleagues and other departments within SLaM and external agencies, e.g. KHP
    • To participate when required in the processes of setting clinical standards and establishing appropriate monitoring To design and manage electronic spread sheets / databases as part of clinical audit projects undertaken in the borough/directorate, and also to carry out appropriate data analysis and present appropriate graphical representation of audit / project results
  • Complaints and SIs
    • Be a member of the Operations Directorate SI & Complaints panel, implement a monitoring system of progress and implementation of any SI/Complaint recommendations and present to the panel meetings, and be accountable for assuring the Chairs of these panels that implementation of recommendations from Complaints, SIs and Clinical Audit are
    • Monitor SIs and Complaints against targets, quality control investigation reports before they go to the Operations Directorate SI panel, and provide feedback reports to the committees.
    • To monitor and report Spot Checks (including sourcing evidence and assurance) locally to relevant SI and Complaints committees.
    • To identify learning needs and themes from SI and Complaint recommendations and ensuring their integration into clinical pathway learning and development objectives.
    • Maintain the information on the DATIX system for individual Serious Incidents and ensure that there is a process for anonymising all incidents To have daily oversight of all Operations Directorate Incidents, complaints and compliments and ensure appropriate systems are implemented and maintained.
    • Provide information to external stakeholders, for example: Commissioners to manage action plans on behalf of the Operations Directorate SI Panel and present recommendations to the panel meetings.
    • Patient Experience and Equality
    • In conjunction with the Operations Directorate Involvement Lead to provide regular reporting including the identification of themes to the Senior Management Group. To support the Involvement Lead to ensure the equality agenda is disseminated to all clinical teams.
    • To provide support and training to other staff in the department on the management of incident, complaints and the Datix system.
  • Training and Education
    • To deliver training and education on all aspects of clinical governance to Operations Directorate teams as required by the Operations Directorate, and to evaluate the effectiveness of such training.
    • To use learning from SIs and audits to highlight training needs to the Training & Education Committee.
    • To maintain an up to date personal development portfolio and ensure that personal training needs appropriate to the demands of the job are brought to the attention of the Governance lead.

    Person Specification



    • Educated to degree level or equivalent experience


    • Masters qualification or demonstrable equivalent managerial experience
    • Relevant project qualification



    • Experience of research, clinical audit and/or related quality improvement work
    • Evidence of project and management experience and managing multiple projects simultaneously
    • Experience of using clinical audit methodologies and writing report using quantitative and qualitative analysis


    • Experience working in Clinical Governance in NHS
    • Management of complaints



    • Knowledge of clinical audit methodologies
    • Knowledge of structures, concepts and processes of Clinical Governance



    • High levels of organisational skills to schedule multiple projects simultaneously and prioritise own workload to meet audit project and audit programme deadlines and Directorate requirements
    • High level of expertise in numerical, analytical and data management skills. Able to construct and manage databases/spreadsheets for projects. Good analytical skills and able to justify choice of methodology and summarise and interpret results
    • Good verbal and written communication skills, including report writing and presentation skills
    • Ability to establish and maintain administrative systems and processes
    • Ability to lead, support and influence others

    Employer details

    Employer name

    South London and Maudsley NHS Foundation Trust


    Maudsley Hospital

    113 Denmark Hill


    SE5 8AZ

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