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Divisional Quality and Safety Manager

University College London Hospitals NHS Foundation Trust
£66,718 to £76,271 Per annum inclusive of HCAS
Closing date
23 May 2024

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Other Health Profession
Band 8B
Contract Type
Full Time
This role is a key leadership role working with the Divisional Leadership Team (DLT) and alongside the directorate management teams (DMT) to oversee all elements of clinical governance and risk, safety, patient experience and quality of care. The post-holder will be responsible for working with governance leads and staff across the division to set the quality agenda for Queen Square Division (QSD) and provide assurance and oversight of all matters related to patient safety and experience.

The post holder will play a key role in interfacing with the Specialist Hospitals Board team on items related to quality and safety on behalf of the Division. They will ensure Trust systems and processes for patient safety, risk management, patient experience including complaints, inquests and claims, clinical audit, clinical effectiveness and Care Quality Commission improvement and assurance work streams are embedded in the day-to-day work of QSD.Liaising with a range of internal and external stakeholders, the post holder will be expected to lead on the delivery and communication of a range of extremely sensitive and challenging objectives relating to the management of patient safety and risk.

The post holder will play a key role in ensuring the coordination and effective management of divisional governance process, including regular contribution and support of divisional and directorate meetings related to quality.

Main duties of the job

o Work with directorate management teams (General Managers, Matrons, Clinical Directors, Heads of Service) to develop and maintain efficient, proactive and responsive structures for managing clinical service quality and patient safetyo Support the directorates with the dissemination and collection of learning from incidents, near misses and other events in line with the PSIRF agendao Be an expert point of contact for all staff in the Division for advice and guidance on matters related to quality, safety, risk, audit and other key elements of the PSIRF agendao Support the divisional leadership team in the coordination and analysis of quality and safety data, producing reports as required for divisional performance meetingso Work with colleagues across the Specialist Hospitals Board to ensure a consistent approach to elements of clinical governance, risk management and qualityo Support the directorates and the division to prepare for external inspections from oversight bodies, including the CQC or NHSEo Lead the division's approach to Improving Care Rounds (ICRs) ensuring that all leads are involved in process of peer-review and providing constructive feedbacko Coordinate divisional incidents for presentation and the Trust's Incident Review Group (IRG), ensuring that the learning from incidents across the Trust is presented to the division

See Detailed Job Description.

About us

University College London Hospitals NHS Foundation Trust (UCLH) is one of the most complex NHS trusts in the UK, serving a large and diverse population. We provide academically led acute and specialist services, to people from the local area, from throughout the United Kingdom and overseas. Our vision is to deliver top-quality patient care, excellent education, and world-class research.

We provide first-class acute and specialist services across eight sites:
  • University College Hospital (incorporating the Elizabeth Garrett Anderson Wing)
  • National Hospital for Neurology and Neurosurgery
  • Royal National ENT and Eastman Dental Hospitals
  • University College Hospital Grafton Way Building
  • Royal London Hospital for Integrated Medicine
  • University College Hospital Macmillan Cancer Centre
  • The Hospital for Tropical Diseases
  • University College Hospital at Westmoreland Street

We are dedicated to the diagnosis and treatment of many complex illnesses. UCLH specialises in women's health and the treatment of cancer, infection, neurological, gastrointestinal and oral disease. It has world class support services including critical care, imaging, nuclear medicine and pathology.

We are committed to sustainability and have pledged to become a carbon net zero health service, embedding sustainable practice throughout UCLH. We have set an ambitious target of net zero for our direct emissions by 2031 and indirect emissions by 2040.

Job description

Job responsibilities

The post holder will provide support for serious incidents including investigation methodology coaching through the Trusts investigation methodology

To co-ordinate the process for serious incidents, ensuring all relevant parts of the process are undertaken by the appropriate people e.g. supporting staff, Duty of Candour, Being Open and delivery of actions

To quality assure final drafts of investigation and learning response reports prior to submission to the central quality and safety team

To provide training on investigation methodology and on being open

To monitor progress on local investigations and learning responses and ensure leads are aware of timescales for these

To monitor progress with action plans and action plans arising from local investigations, learning responses and other sources/workstreams, gaining robust assurance that changes have been implemented

To ensure action plans reflect current best practice and long term strategic aims of the division to provide the highest levels of patient care.

To support multi-disciplinary teams in ensuring lessons learnt are shared within the Division and the Trust and to ensure relevant Trust learning is shared within the Division.

To provide reports to support the above including detailed analysis of key trends and highlighting outliers to key Divisional and Trust Quality & Safety targets.

Queen Square Division

The Queen Square Division is the largest Division in UCLH with a turnover of around �240m and over 2,000 staff. It comprises the services at the National Hospital for Neurology and Neurosurgery (NHNN) in Queen Square, the Royal London Hospital for Integrated Medicine (RLHIM), the Pain Management Centre at Cleveland Street and the Gower Assessment Unit at the Epilepsy Society, Chalfont St Peter.

The NHNN is the UKs largest dedicated neurological and neurosurgical hospital treating over 6,000 inpatients, 120,000 outpatients and 8,000 day cases each year. Established for over 150 years it provides comprehensive services for the diagnosis, treatment and care of all conditions that affect the brain, spinal cord, peripheral nervous system and muscles.

The RLHIM is the largest public sector provider of integrated complementary medicine in Europe. The hospital offers an innovative, patient-centred service integrating the best of conventional and complementary treatments for a wide range of conditions. The RLHIM operates on an outpatients clinic basis. Clinical services include womens health, complementary cancer care, allergy service, skin clinics, acupuncture, rheumatology service, childrens service, weight loss management, sleep management clinics, musculoskeletal medicine and stress management.

Queen Square provides a wide range of services including:

- Inpatient surgical, medical, rehabilitation, critical care and mental health services

- A full spectrum of outpatients and daycare services across neurosciences, pain management and integrated medicine

- Diagnostics including imaging, pathology and many other diagnostic services

- Other services including pharmacy, private patient services and more

Its facilities include 6 conventional theatres and an interventional MRI suite, neuroscience critical care unit, over 200 beds, a day-care unit and extensive outpatient facilities. It also houses the Wolfson Experimental Neurology clinical research centre. There are referral pathways and shared appointments with a variety of London hospitals.

For the full Person Specification and more information regarding the main responsibilities of this role, please refer to the attached Job Description.

Come and be a part of the best NHS trust in England to work for, according to our staff*

UCLH top trust to work at in England for the second year running! : University College London Hospitals NHS Foundation Trust

*In the most recent NHS staff survey UCLH had the highest percentage of staff who said they would recommend us as a place to work, out of all general acute or acute/community NHS trusts in England for the second year in a row.

UCLH top trust to work at in England for the second year running! : University College London Hospitals NHS Foundation Trust.

Once again, UCLH has received the highest score of all general acute and acute/community NHS trusts in England for staff that would recommend us as a place to work.

Person Specification

Knowledge and Qualifications


  • Educated to Masters level or equivalent evidence of successful study at a higher level within a specialist environment of clinical effectiveness/project management
  • Management qualification or equivalent experience of leading and developing individuals and teams


  • Clinical background / qualification e.g. first level nursing or AHP qualification



  • Experience of significant period of time working in the NHS, in at least 3 relevant fields e.g. audit, guidelines, complaints, risk, CQC work, claims.
  • Understanding of the NHS Complaints procedure and current national issues.
  • Appreciation of the critical issues in the management of complaints
  • Experience and/or involvement in the complaint investigation process
  • Experience in the management of serious incidents
  • Expertise in investigative processes (e.g. Root Cause Analysis RCA - E, PSIRF)
  • Experience of working in a large and complex health environment at corporate level (or on trust wide issues)
  • Detailed knowledge and understanding of the Care Quality Commission regulations and PSIRF agenda
  • Knowledge of quality and safety clinical governance policy framework and related documents


  • Detailed demonstrable knowledge and experience of clinical effectiveness e.g. principles and practice of clinical audit methodologies and clinical guideline development/implementation and monitoring
  • Awareness of Government policies and strategies in relation to clinical effectiveness

Skills and Abilities


  • Ability to negotiate and influence front line and management staff at all levels particularly where proposed approaches to incident management may differ
  • Articulate, influential and persuasive
  • Ability to work across boundaries and breakdown barriers
  • Demonstrable knowledge and experience of critical appraisal skills / the ability to evaluate and critically appraise information
  • Ability to plan and organise a varying work load effectively to meet deadlines in the short and long term.
  • A flexible approach to work with the ability to react accordingly to changing demands and work priorities



  • Demonstrate ability to meet Trust Values of safety, kindness, teamwork and improving



  • Advanced written skills with experience of different writing styles including reports, action plans, summaries and policies.
  • Ability to prepare and deliver presentations to all levels of an organisation
  • Understanding of Confidentiality

Personal and People Development


  • Able to function within a team as team leader or team member
  • The ability to encourage, enthuse and lead others


  • Experience in training and/or coaching

Responsibilities towards promoting Equality Diversity and Inclusion


  • Demonstratable understanding of the Equality, Diversity, and Inclusion and/or Knowledge of the NHS obligations under the Equality Act 2010 and the Public Sector Equality Duties

Ensure the risk of infection to self, colleagues, patients, relatives and visitors is minimised by:


  • Being familiar with, and adhering to Trust policies and guidance on infection prevention and control.
  • Taking personal responsibility so far as is reasonably practicable, in helping ensure that effective prevention and control of health care associated infections is embedded into everyday practice and applied consistently.

Employer details

Employer name

University College London Hospitals NHS Foundation Trust


National Hospital for Neurology & Neurosurgery

Queen Square



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