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Head of Quality and Governance

Independent Health Group
Bath Business Park, Bath
£50,000 per year plus discretionary 5% bonus
Closing date
12 Oct 2023
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An exciting opportunity has arisen for a well-motivated individual to join Independent Health Group (IHG) as Head of Quality and Governance.

The Head of Quality and Governance is a member of the Senior Management Team and has overall responsibility for being the CQC Registered Manager as well as the organisational lead for Health and Safety.

The post holder will work closely with clinical teams to support the delivery of safe effective care to meet and exceed regulatory standards. You will review clinical governance data and clinical practice outcomes whilst supporting the application of the Governance framework for continual improvement.

In addition to a competitive salary, Independent Health Group also offers a generous pension contribution of 6% of your qualified earnings.

We offer 25 days annual leave, a day off for your birthday (if it falls on one of your working days), bank holidays, plus the option to buy up to an additional 2 weeks.

Main duties of the job

  • You will provide strategic support, guidance, and development of robust clinical governance frameworks, ensuring we can deliver and evidence the very best practice, safety and quality standardised care across all sites.
  • You will champion our values and culture of excellence creating a culture where continuous improvement and learning are the norm.
  • You will lead the organisational Risk, Patient Safety, Quality and Governance strategy and related performance activities to ensure compliance with all applicable regulations.
  • You will provide assurance to the organisation and other stakeholders that the highest standards of quality and patient safety are maintained.
  • You will review, develop, maintain and monitor systems of clinical governance, Patient Safety and Quality Improvement.
  • You will work in partnership with the Head of Clinical Services, Matrons and Senior Clinical and operational staff, to ensure services are delivered in a safe and effective way.

About IHG

Independent Health Group (IHG) was set up in 2004 by Dr Matthew Wordsworth with the aim of offering patients the choice of being treated out of hospital, closer to home. Matt wanted to create a new health care organisation in which like-minded health care professionals could deliver truly patient centred care. Our aim was to be a leading provider of community-based diagnostic and treatment services of the highest quality, where patients always come first. In the summer of 2022 we were proud to receive an OUTSTANDING CQC rating.

Since 2004 we have grown the range of services we offer, and the sites we work from, and we believe that IHG offers you an opportunity to make a real difference to patients care and treatment. We pride ourselves on the quality of care we offer our patients. IHG provides services from several locations in Wiltshire, Leicester, Gloucester and Devon, providing surgical services including hand surgery, podiatric surgery, hernia, vasectomy and ophthalmology. All the work we undertake is for the NHS

We work in a different kind of environment to that of an acute hospital setting. Our patients see the same clinician and are offered specific appointment times. Our staff work within small teams with plenty of time for patient contact. Working with us will offer you the opportunity to contribute to the development of a fantastic organisation, as well as the opportunity to develop your skills and knowledge in a health care setting.

Job description 

Quality and governance framework

  • Develop, maintain and monitor the Clinical Governance and Quality Assurance framework.
  • Update the Clinical governance and quality assurance framework in response to service developments, changes in clinical practice, or regulation, and thereby provide assurance internally and externally.
  • Provide the organisation with oversight on developments in clinical governance, patient safety and Health and Safety regulation.
  • Support the organisation with quality improvement initiatives.
  • To ensure there is a framework of policies and standard operational procedures in place and they are applied consistently to ensure services are safe and effective.
  • Maintain the organisations Risk Register, specifically ensuring clinical/operational risks are recorded and actions are taken within services to mitigate these risks.
  • Work with all colleagues to ensure effective systems are in place to comply with the requirements for regulation including the essential standards of quality and safety e.g. CQC and risk management e.g. CAS Alerts/NICE Guidance.
  • Interpret statutory legislation and guidance for the development and monitoring of Governance policies, procedures, protocols and safe systems of work and support managers in the implementation of these.
  • Exercise expert judgement involving highly complex facts, statistical data and multifaceted situations that require the analysis, interpretation and comparison of a range of options, which support improved risk management, embed governance and improved patient services across the Service.

Maintain and monitor services

  • Work with senior operational and clinical staff to ensure standard operating procedures and other guidelines or protocols are communicated, reflect best practice and ensure we have safe systems of work.
  • In conjunction with the Head of Clinical Services ensure clinical practice and clinic standards are up to date by cascading updates, safety alerts and notices to staff and ensuring they are actioned (e.g. CAS, health and safety, NICE guidance etc)
  • Provide a framework for auditing services, and ensure a programme of audits are undertaken by operational services, and actions taken in response to those audits
  • Provide the quality visit framework, ensure the service lead undertakes safety audits, and follow up actions are completed.
  • To manage and lead the organisations PSIRP and Electronic Risk and event management system, undertaking, monitoring and coordinating internal and external investigations and ensuring improvement actions are identified and taken including reporting of significant events.
  • Manage the complaints and concerns process, ensuing all complaints and concerns are handled in a timely and considerate manner in line with policy and process, and support the management of any legal claims.


  • Produce high quality, monthly, quarterly, and annual reports for both internal and external requirements that highlight successes and opportunities for improvement and development, this includes leading on the creation of the annual quality account, supporting quality priorities and operational delivery and achievement of agreed quality targets.
  • Maintain complete and timely records of actions to support governance and quality.
  • Undertake regular thematic analyse of all key Quality Metric such as, patient safety events, patient feedback, reporting on trends and highlighting risks or issues.

Health and safety framework

  • Lead the health and safety agenda, ensuring the organisation operates safe systems of work, and has the appropriate framework of Risk Assessments, policies, SOPs and training in place.

Management and leadership

  • As a member of the Senior management team ensure that IHG meets its activity, performance and financial targets, and operates to the highest standards of corporate and clinical governance.
  • Provides leadership to ensure that the culture of incident reporting is embedded across the organisation. This includes management of the incident reporting system, identifying trends and providing assurance and learning from incidents to the Integrated Governance and Business committee / clinical & non-clinical teams.
  • Hold direct line management responsibilities for the the Quality and Governance Assistant and new team members as the organisation grows - To undertake all direct line management functions including Recruitment, Appraisals / Performance reviews, Sickness reviews, ensuring all mandatory, statutory and competency training is undertaken and staff who report to you comply with relevant HR policies.

Person Specification

Qualifications- Essential

  • Degree in relevant field, or equivalent experience

Qualifications- Desirable

  • A registered health care professional with evidence of continuous professional development
  • Patient Safety and investigation qualification/s or equivalent experience Medico-legal qualification or equivalent experience
  • Quality Improvement qualification or equivalent experience
  • Health and Safety qualification of equivalent experience

Knowledge and Skills- Essential

  • CQC Registered Manager
  • Experience of managing and overseeing a Risk and Incident Management System
  • Knowledge of clinical and corporate governance, regulatory frameworks, and service improvement mechanisms
  • Excellent understanding of the importance of delivering high quality clinical care and the factors that influence it.
  • Able to communicate effectively with patients and colleagues in a variety of settings and with differing levels of understanding
  • Good analytical/critical reasoning skills.
  • Able to present written and verbal information clearly and concisely
  • Self-motivated and able to work autonomously Willing and able to challenge

Experience -Essential

  • Leading a quality or governance service in the health or care sector
  • Preparing and presenting quality data to stakeholders
  • Planning, implementing and analysing audits Clinical governance and risk management.
  • Lead the management of serious incidents, including their investigation and action planning.
  • Staff management Initiating and implement changes that improve the patients experience.

Experience- Desirable

  • Operating in a dispersed, multi-site setting
  • Working in an organisation providing surgery.

Personal Competencies- Essential

  • Able to lead, influencing and communicating effectively with all key stakeholders
  • Ability to make decisions effectively and prioritise workload
  • Collaborative and willing to work with/through others.
  • Committed to the highest standards of care and continuous improvement

For further information about this role, or for an informal discussion, please contact Claire Damen, Chief Executive Officer at If you would prefer to send your CV with a covering letter, please send this to Please note: We regret that we are unable to accept applications from overseas candidates at this time.

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