Job summary

You will lead the Governance and Education Team, with responsibility for patient safety, risk management, clinical audit, quality improvement, policy oversight and regulatory assurance. You will provide clear reporting to the Director of Clinical Services and, through the Director, to senior leaders and Trustees. You will also deputise for the Director of Clinical Services within agreed responsibilities and participate in the senior on-call rota. There is scope to take on Registered Manager responsibilities in future, subject to organisational requirements, mutual agreement and CQC registration.

Main duties of the job

The Head of Governance, Quality and Patient Safety is a senior leadership role within the Care Directorate. The post holder provides strategic and operational leadership for governance, quality assurance, patient safety, risk management, clinical effectiveness and regulatory compliance across Haven House Childrens Hospice. The post holder will lead the organisations governance and quality systems, ensuring robust processes are in place to support the delivery of safe, effective, caring, responsive and well-led services. They will provide assurance to the Director of Clinical Services, who is the executive lead for quality and safety, and through the Director to the Executive Team, Board Committees and Board of Trustees. The post holder will act as the organisational lead for CQC readiness under the Single Assessment Framework, maintaining continuous preparedness and oversight of evidence, compliance and improvement activity. Deputise for the Director of Clinical Services, as required, in relation to governance, quality, patient safety, regulatory assurance and CYP/family experience within agreed delegated authority. There is scope for the post holder to take on Registered Manager responsibilities in future, subject to organisational requirements, mutual agreement and CQC registration.

About us

At Haven House, we support children and young people with life-limiting and life-threatening conditions, alongside their families. We are looking for an experienced nurse or allied health professional to lead our governance, quality and patient safety work, helping us deliver the best possible care. This is a senior leadership role within our Care Directorate, working closely with the Director of Clinical Services and teams across the hospice. You will lead our governance and assurance systems, support continuous CQC readiness and ensure that learning leads to meaningful, lasting improvements in practice. The voices and experiences of children, young people and families will be central to your work. You will bring together feedback, incident learning, audit findings and service outcomes to understand where we are doing well, where we need to improve and whether our actions are making a difference.

Details

Date posted

09 October 2026

Pay scheme

Agenda for change

Band

Band 8a

Salary

£57,528 to £60,417 a year plus Outer London Allowance

Contract

Permanent

Working pattern

Full-time, Flexible working

Reference number

B0186-26-0026

Job locations

The White House

Woodford Green

Essex

IG8 9LB

United Kingdom

Job description

Job responsibilities

Key ResponsibilitiesGovernance and QualityOwn the organisational governance and assurance framework, with individual service leads remaining accountable for the delivery and reporting of safe practice, compliance and improvement within their areas. Identify and escalate gaps in assurance to the Director of Clinical Services.Ensure the voice and experience of children, young people and families is embedded within quality governance and assurance, with feedback, experience data, complaints, compliments and co-production used to identify themes, drive improvement and evidence impact.Maintain oversight of governance structures, terms of reference and reporting arrangements, ensuring clear lines of accountability to Board.Develop and maintain quality, patient safety and experience dashboards and metrics to support organisational oversight and assurance.Produce regular governance, quality, safety and experience reports for the Director of Clinical Services, SLT, Board Committees and Trustees.Lead the production of the annual Quality Account in partnership with the Director of Clinical Services.Own the organisational governance assurance action tracker, actively drive delivery with responsible leads, escalate slippage and provide evidence of closure and sustained improvement.Patient Safety and LearningAct as the organisational lead for patient safety and incident managementLead implementation of the Patient Safety Incident Response Framework (PSIRF), including the Patient Safety Incident Response Plan, proportionate learning responses and patient safety incident investigations.Ensure incidents are recorded through the Learn from Patient Safety Events (LFPSE) service and that local reporting systems are effective.Lead the Duty of Candour framework and provide assurance regarding compliance.Maintain strategic oversight of complaints, concerns and compliments, ensuring responses are timely and learning is captured.Lead thematic reviews and ensure learning from incidents, complaints, audits, safeguarding reviews, child death reviews and family feedback is embedded into practice.Establish and maintain systems to verify that actions arising from incidents, audits, complaints, regulatory reviews and investigations have been implemented effectively, embedded in practice and resulted in sustained improvement.Support the organisations contribution to child death review processes, including Child Death Overview Panel (CDOP) and National Child Mortality Database (NCMD) requirements. Maintain oversight of medicines safety governance, working with the Director of Clinical Services and pharmacy partners. Ensure learning from Freedom to Speak Up concerns is reflected in governance reporting, working with the Freedom to Speak Up Guardian.CQC and Regulatory AssuranceLead organisational readiness for assessment and inspection under the CQC Single Assessment Framework Maintain oversight of compliance with relevant legislation, CQC regulations, national standards and professional guidance. Develop and maintain a comprehensive evidence repository and compliance platform demonstrating quality outcomes.Coordinate organisational responses to inspections, regulatory enquiries, statutory notifications and assurance reviews.Deputise for the Director of Clinical Services/Registered Manager as required, within agreed delegated authority, and support the discharge of Registered Manager responsibilities.Lead mock inspections and internal assurance reviews and develop action plans to address gaps.Monitor developments in legislation, regulation, national policy and guidanceand advise on their implications and recommended actions. Support senior leaders and Trustees in understanding regulatory requirements, including Well-Led expectationRisk Management, Audit and AssuranceLead the clinical risk management framework and maintain the clinical risk register, ensuring alignment with organisational and strategic risk registers.Ensure effective systems for risk identification, assessment, mitigation and escalation.Lead the development and delivery of the annual clinical audit and assurance programme.Ensure audit findings and assurance reviews result in measurable, sustained improvements, with completed actions tested to confirm that changes are embedded in practice and effective over time.Oversee service evaluation, quality assurance and performance monitoring activity.Clinical Effectiveness and Quality ImprovementLead the organisational Quality Improvement Strategy and promote the use of quality improvement methodology across services.Maintain oversight of clinical effectiveness programmes and the implementation of NICE and other national guidance.Ensure service development is driven by outcome measures, audit findings and feedback from children, young people and families.Champion innovation and improvement initiatives that enhance care and experience for children, young people and families.Policy and Information GovernanceLead the organisational policy management framework, including development, consultation, review, ratification and implementation. Maintain document control and version management systems, ensuring policies are compliant, current and accessible.Support information governance arrangements, including completion of the Data Security and Protection Toolkit (DSPT).Act as Caldicott Guardian as designated by the organisation.SafeguardingSupport the Designated Safeguarding Lead and team in the governance and assurance of safeguarding arrangements. Ensure safeguarding learning, audit findings and assurance activity are integrated into the wider governance and quality framework.Education and Workforce DevelopmentProvide strategic oversight of clinical education, training and competency frameworks delivered by the Education and Governance Team.Ensure education programmes respond to learning from incidents, audits, complaints and regulatory findings.Maintain oversight of mandatory and clinical training compliance and report on it through governance structures.Lead the development of governance and quality improvement capability across the organisation.Leadership and ManagementProvide professional leadership and line management to the Education and Governance Team, including supervision, appraisal, wellbeing and professional development. Foster a culture of openness, accountability, psychological safety, learning and continuous improvement.Support workforce development and succession planning within the governance function.Address performance, conduct and capability concerns in line with organisational policies.Participate in the senior on-call rota and deputise for the Director of Clinical Services where delegated, including governance decision-making, incident escalation, regulatory matters and quality and patient safety assurance within agreed authority.Collaborative WorkingWork collaboratively with clinical, operational and corporate leaders to improve governance, quality and safety. Hold leads to account for delivery of governance and assurance actions and escalate failures of assurance to the Director of Clinical Services. Build strong relationships with external partners, including NHS organisations, the Integrated Care Board, regulators and professional networks. Provide specialist governance advice to service developments, transformation programmes and strategic projects. Represent Haven House at internal and external meetings relating to governance, quality, patient safety and regulatory matters.

Designated Lead Roles - PLEASE REFER TO THE JOB DESCRIPTION FOR MORE INFORMATION.

.Controlled Drugs Accountable Officer -PLEASE REFER TO THE JOB DESCRIPTION FOR MORE INFORMATION.

This job description is not a definitive or exhaustive list of responsibilities but identifies the key responsibilities and tasks of the post holder. The specific objectives of the post holder will be subject to review as part of the individual performance process.Haven House is committed to Equal Opportunities in Employment and therefore it is our aim to ensure that no applicant or employee receives less favourable treatment on grounds of gender, disability, religion, race, colour, sexual orientation, and nationality, ethnic or national origins or is placed at a disadvantage by conditions or requirements which cannot be shown to be justifiable.Haven House is responsible under the existing equality and diversity legislation to ensure equality issues are promoted and you are expected to work with Haven House to fulfil these obligations, policies and codes of good practice.Employees must take reasonable care and be aware of the responsibilities placed on them under the Health & Safety at Work Act (1974) and to ensure that agreed safety procedures are carried out to maintain a safe environment for employees, patients and visitors.Haven House is committed to safeguarding and promoting the welfare of children and young people and expects all staff to share this commitment. Employment is subject to receipt of satisfactory references and an enhanced DBS check.

PLEASE REFER TO THE JOB DESCRIPTION FOR MORE KEY RESPONSIBILITIES.

Job description Job responsibilities Key ResponsibilitiesGovernance and QualityOwn the organisational governance and assurance framework, with individual service leads remaining accountable for the delivery and reporting of safe practice, compliance and improvement within their areas. Identify and escalate gaps in assurance to the Director of Clinical Services.Ensure the voice and experience of children, young people and families is embedded within quality governance and assurance, with feedback, experience data, complaints, compliments and co-production used to identify themes, drive improvement and evidence impact.Maintain oversight of governance structures, terms of reference and reporting arrangements, ensuring clear lines of accountability to Board.Develop and maintain quality, patient safety and experience dashboards and metrics to support organisational oversight and assurance.Produce regular governance, quality, safety and experience reports for the Director of Clinical Services, SLT, Board Committees and Trustees.Lead the production of the annual Quality Account in partnership with the Director of Clinical Services.Own the organisational governance assurance action tracker, actively drive delivery with responsible leads, escalate slippage and provide evidence of closure and sustained improvement.Patient Safety and LearningAct as the organisational lead for patient safety and incident managementLead implementation of the Patient Safety Incident Response Framework (PSIRF), including the Patient Safety Incident Response Plan, proportionate learning responses and patient safety incident investigations.Ensure incidents are recorded through the Learn from Patient Safety Events (LFPSE) service and that local reporting systems are effective.Lead the Duty of Candour framework and provide assurance regarding compliance.Maintain strategic oversight of complaints, concerns and compliments, ensuring responses are timely and learning is captured.Lead thematic reviews and ensure learning from incidents, complaints, audits, safeguarding reviews, child death reviews and family feedback is embedded into practice.Establish and maintain systems to verify that actions arising from incidents, audits, complaints, regulatory reviews and investigations have been implemented effectively, embedded in practice and resulted in sustained improvement.Support the organisations contribution to child death review processes, including Child Death Overview Panel (CDOP) and National Child Mortality Database (NCMD) requirements. Maintain oversight of medicines safety governance, working with the Director of Clinical Services and pharmacy partners. Ensure learning from Freedom to Speak Up concerns is reflected in governance reporting, working with the Freedom to Speak Up Guardian.CQC and Regulatory AssuranceLead organisational readiness for assessment and inspection under the CQC Single Assessment Framework Maintain oversight of compliance with relevant legislation, CQC regulations, national standards and professional guidance. Develop and maintain a comprehensive evidence repository and compliance platform demonstrating quality outcomes.Coordinate organisational responses to inspections, regulatory enquiries, statutory notifications and assurance reviews.Deputise for the Director of Clinical Services/Registered Manager as required, within agreed delegated authority, and support the discharge of Registered Manager responsibilities.Lead mock inspections and internal assurance reviews and develop action plans to address gaps.Monitor developments in legislation, regulation, national policy and guidanceand advise on their implications and recommended actions. Support senior leaders and Trustees in understanding regulatory requirements, including Well-Led expectationRisk Management, Audit and AssuranceLead the clinical risk management framework and maintain the clinical risk register, ensuring alignment with organisational and strategic risk registers.Ensure effective systems for risk identification, assessment, mitigation and escalation.Lead the development and delivery of the annual clinical audit and assurance programme.Ensure audit findings and assurance reviews result in measurable, sustained improvements, with completed actions tested to confirm that changes are embedded in practice and effective over time.Oversee service evaluation, quality assurance and performance monitoring activity.Clinical Effectiveness and Quality ImprovementLead the organisational Quality Improvement Strategy and promote the use of quality improvement methodology across services.Maintain oversight of clinical effectiveness programmes and the implementation of NICE and other national guidance.Ensure service development is driven by outcome measures, audit findings and feedback from children, young people and families.Champion innovation and improvement initiatives that enhance care and experience for children, young people and families.Policy and Information GovernanceLead the organisational policy management framework, including development, consultation, review, ratification and implementation. Maintain document control and version management systems, ensuring policies are compliant, current and accessible.Support information governance arrangements, including completion of the Data Security and Protection Toolkit (DSPT).Act as Caldicott Guardian as designated by the organisation.SafeguardingSupport the Designated Safeguarding Lead and team in the governance and assurance of safeguarding arrangements. Ensure safeguarding learning, audit findings and assurance activity are integrated into the wider governance and quality framework.Education and Workforce DevelopmentProvide strategic oversight of clinical education, training and competency frameworks delivered by the Education and Governance Team.Ensure education programmes respond to learning from incidents, audits, complaints and regulatory findings.Maintain oversight of mandatory and clinical training compliance and report on it through governance structures.Lead the development of governance and quality improvement capability across the organisation.Leadership and ManagementProvide professional leadership and line management to the Education and Governance Team, including supervision, appraisal, wellbeing and professional development. Foster a culture of openness, accountability, psychological safety, learning and continuous improvement.Support workforce development and succession planning within the governance function.Address performance, conduct and capability concerns in line with organisational policies.Participate in the senior on-call rota and deputise for the Director of Clinical Services where delegated, including governance decision-making, incident escalation, regulatory matters and quality and patient safety assurance within agreed authority.Collaborative WorkingWork collaboratively with clinical, operational and corporate leaders to improve governance, quality and safety. Hold leads to account for delivery of governance and assurance actions and escalate failures of assurance to the Director of Clinical Services. Build strong relationships with external partners, including NHS organisations, the Integrated Care Board, regulators and professional networks. Provide specialist governance advice to service developments, transformation programmes and strategic projects. Represent Haven House at internal and external meetings relating to governance, quality, patient safety and regulatory matters.Designated Lead Roles - PLEASE REFER TO THE JOB DESCRIPTION FOR MORE INFORMATION..Controlled Drugs Accountable Officer -PLEASE REFER TO THE JOB DESCRIPTION FOR MORE INFORMATION.This job description is not a definitive or exhaustive list of responsibilities but identifies the key responsibilities and tasks of the post holder. The specific objectives of the post holder will be subject to review as part of the individual performance process.Haven House is committed to Equal Opportunities in Employment and therefore it is our aim to ensure that no applicant or employee receives less favourable treatment on grounds of gender, disability, religion, race, colour, sexual orientation, and nationality, ethnic or national origins or is placed at a disadvantage by conditions or requirements which cannot be shown to be justifiable.Haven House is responsible under the existing equality and diversity legislation to ensure equality issues are promoted and you are expected to work with Haven House to fulfil these obligations, policies and codes of good practice.Employees must take reasonable care and be aware of the responsibilities placed on them under the Health & Safety at Work Act (1974) and to ensure that agreed safety procedures are carried out to maintain a safe environment for employees, patients and visitors.Haven House is committed to safeguarding and promoting the welfare of children and young people and expects all staff to share this commitment. Employment is subject to receipt of satisfactory references and an enhanced DBS check.PLEASE REFER TO THE JOB DESCRIPTION FOR MORE KEY RESPONSIBILITIES.

Person Specification

Qualifications

Essential

• Registered Nurse or Allied Health Professional with current NMC or HCPC registration, as applicable.
• Degree in Nursing, Healthcare or related subject
• Patient Safety Syllabus training (Levels 1 and 2) or willingness to complete

Desirable

• Masters degree or equivalent experience

Skills and Abilities

Essential

• Strong leadership and organisational skills
• Excellent communication and influencing skills
• Ability to analyse complex information and provide assurance
• Ability to manage risk and respond to emerging concerns
• Excellent report writing and presentation skills
• Ability to lead quality improvement and change programmes
• Strong stakeholder engagement and partnership-working skills
• Ability to manage competing priorities and meet deadlines
• High level of emotional intelligence, resilience and professional judgement

Experience

Essential

• Significant leadership experience in governance, quality and patient safety
• Experience within childrens services, hospice care, palliative care or complex healthcare services
• Experience of CQC compliance and inspection preparation
• Experience leading governance, risk management and assurance systems
• Working knowledge of PSIRF and experience leading patient safety incident responses and organisational learning
• Experience of governance and assurance
• Experience leading audit programmes and quality improvement initiatives
• Experience producing committees, Boards or equivalent
• Experience leading multidisciplinary team

Desirable

• Experience of safeguarding children and young people
• Experience as a CQC Registered Manager or Deputy Registered Manager
• Experience of Controlled Drugs governance or acting as a Controlled Drugs Accountable Officer
• Experience of child death review processes (CDOP/NCMD)
• Experience of service transformation and organisational improvement programmes

Knowledge

Essential

• Strong knowledge of the CQC Single Assessment Framework

Desirable

• Knowledge of information governance, including the DSPT

Personal Qualities

Essential

• Visible and credible leader
• Calm, resilient and solution-focused
• Values-led with strong professional integrity
• Commitment to safeguarding children and young people
• Commitment to equality, diversity and inclusion
• Collaborative and supportive approach
• Passion for quality improvement and patient safety

Person Specification Qualifications Essential Registered Nurse or Allied Health Professional with current NMC or HCPC registration, as applicable. Degree in Nursing, Healthcare or related subject Patient Safety Syllabus training (Levels 1 and 2) or willingness to complete Desirable Masters degree or equivalent experience Skills and Abilities Essential Strong leadership and organisational skills Excellent communication and influencing skills Ability to analyse complex information and provide assurance Ability to manage risk and respond to emerging concerns Excellent report writing and presentation skills Ability to lead quality improvement and change programmes Strong stakeholder engagement and partnership-working skills Ability to manage competing priorities and meet deadlines High level of emotional intelligence, resilience and professional judgement Experience Essential Significant leadership experience in governance, quality and patient safety Experience within childrens services, hospice care, palliative care or complex healthcare services Experience of CQC compliance and inspection preparation Experience leading governance, risk management and assurance systems Working knowledge of PSIRF and experience leading patient safety incident responses and organisational learning Experience of governance and assurance Experience leading audit programmes and quality improvement initiatives Experience producing committees, Boards or equivalent Experience leading multidisciplinary team Desirable Experience of safeguarding children and young people Experience as a CQC Registered Manager or Deputy Registered Manager Experience of Controlled Drugs governance or acting as a Controlled Drugs Accountable Officer Experience of child death review processes (CDOP/NCMD) Experience of service transformation and organisational improvement programmes Knowledge Essential Strong knowledge of the CQC Single Assessment Framework Desirable Knowledge of information governance, including the DSPT Personal Qualities Essential Visible and credible leader Calm, resilient and solution-focused Values-led with strong professional integrity Commitment to safeguarding children and young people Commitment to equality, diversity and inclusion Collaborative and supportive approach Passion for quality improvement and patient safety

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.

UK Registration

Applicants must have current UK professional registration. For further information please see NHS Careers website (opens in a new window).

Additional information 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. UK Registration Applicants must have current UK professional registration. For further information please see NHS Careers website (opens in a new window).

Employer details

Employer name

Haven House Children’s Hospice

Address

The White House

Woodford Green

Essex

IG8 9LB

United Kingdom

Employer's website

https://www.havenhouse.org.uk/ (Opens in a new tab)

Employer details

Employer name

Haven House Children’s Hospice

Address

The White House

Woodford Green

Essex

IG8 9LB

United Kingdom

Employer's website

https://www.havenhouse.org.uk/ (Opens in a new tab)