Go back Ashford & St. Peter’s Hospitals NHS Foundation Trust
Divisional Governance Lead (FIXED TERM 6 MONTHS)
The closing date is 15 April 2026
We are seeking an experience nurse/registered practitioner to support the medical division with governance. The general and specialist Medical division is a busy division with eleven inpatient wards, four ambulatory units/ services and a busy outpatient delivery service.
The person will support the governance framework and patient experience for the division alongside the leadership and ward teams.
The post is currently being offered as a six month fixed term contract and we welcome interested individuals to get in contact with either Janet McAuley Divisional Chief Nurse 01932 72190 or janet.mcauley@nhs.net or Emma Reed Head of Nursing on 07729 079906.
Main duties of the job
Take a lead in the Quality Governance Assurance Framework ensuring that the quality of care in the division, patient experience, patient safety and clinical effectiveness is of the highest standard, meeting national and local outcomes.
Provide information relating to the divisional compliance with CQC ensuring that Health Assure is updated in a timely way.
Ensure that the Quality, Safety and Risk Management Framework is embedded in the division.
Co‑ordinate clinical and non‑clinical risk management activities across the division.
To report regularly and liaise with Divisional Chief Nurse and Associate Director of Nursing on developments within the division and organisation, learning from incidents, risk management, audit and in‑service education.
To monitor incidents/events recorded via the Trust reporting system relating to the division in order to co‑ordinate and communicate actions taken locally and disseminate appropriately any issues that could promote organisational learning.
Prepare reports for discussion relating to the division.
To keep abreast of the National Agenda in regards to Patient Safety. Ensure dissemination of the Patient Safety Alerts from the NPSA and co‑ordinate the responses to ensure that appropriate action plans are in place.
Take a lead on co‑ordinating Patient Experience, PALs and complaints.
About us
Ashford and St. Peters Hospitals NHS Foundation Trust serves a population of more than 410,000 people living in North‑West Surrey, parts of Hounslow and beyond.
Over 3,700 highly trained doctors, nurses, midwives, therapists, healthcare scientists and other support staff make up our workforce, providing a wide range of services across our two hospital sites, Ashford, Surrey and St Peter’s, Chertsey, Surrey.
We also run many specialist clinics in the community and local community hospitals and other healthcare facilities.
Our vision is to be one of the best healthcare Trusts in the country. There has never been a better time to join us in the NHS at ASPH. We are committed to providing continuous professional development and flexibility to shape our workforce around our patient care.
We are expanding our theatres at Ashford Hospital and moving towards this becoming our dedicated elective centre. We want to create a state‑of‑the‑art centre for excellence for planned surgical procedures.
We can offer you the full range of NHS benefits/discounts and in addition:
- Excellent pension scheme and annual leave entitlement
- On‑site Nurseries
- On‑site staff cafes
- On‑site parking
- Salary Sacrifice schemes including wage stream, lease cars, Cycle to Work schemes and home electronics
Adverts may close early, so applicants are encouraged to submit an application as soon as possible.
For more information about a career at ASPH please visit:www.asph-careers.org
Job responsibilities
Internally the post holder will develop effective working relationships with:
- Clinicians and Nursing Staff
- Admin & Clerical Staff
- Quality Department
1. MAIN DUTIES AND RESPONSIBILITIES OF THE POST:
Quality Responsibilities:
- In conjunction with the Divisional Chief Nurse, Head of Nursing, Matrons, Lead Nurse for Stroke, Associate Director Operations and Divisional Director assess and review compliance with governance and CQC standards.
- Lead and maintain the PSIRF dashboards and co‑ordinate the investigative process supporting wards and leadership team to carry out appropriate meetings.
- Lead on closing and supporting actions and learning across the division.
- Identify and cascade to senior leadership team any immediate risk or actions which occur as part of the incident reporting system.
- Support the completion of Duty of Candour statutory letters through the division.
- In conjunction with the Divisional Chief Nurse, Head of Nursing, Matrons, Lead Nurse for Stroke, Associate Director Operations and Divisional Director take responsibility for tracking all complaints relating to the division.
- In conjunction with the Divisional Chief Nurse and Patient Experience Team assist with investigation and actions as a result of complaints.
- Contribute to the development of effective strategies, policies and processes across the Division.
- Develop and implement systems to identify opportunities for learning and sharing good practice creating learning opportunities for the division.
- Work with senior clinicians to monitor the implementation of NICE guidelines, National Service Frameworks and NCEPOD recommendations.
- Support report writing for EPSIP meetings and governance meetings.
- Work with all divisional teams to ensure speciality governance meetings are taking place and feed into the divisional governance meetings.
- Monitor PSIRF training and compliance.
- In conjunction with the leadership team, be responsible for delivering the Quality, Safety and Risk Management Strategy.
- Lead and collate the evidence/information required from the division regarding the NHSLA risk management standards.
- Be responsible for following up any events causing concern with the appropriate nurse/clinician.
- Take the lead in reporting incident events to the Divisional Governance Group, contributing to any action planning as a result of an event and supporting staff to implement the identified actions.
- Advise and support staff to undertake Root Cause Analysis Training investigation process.
- Facilitate a proactive approach to risk management through support of risk assessment process in helping to populate the Trust risk register and ensuring regular reviews and updates are maintained.
- Ensure recommended action is taken as a result of risk management investigations.
Education responsibilities:
- Take a lead role in the provision of governance training within the division.
- To ensure all staff are aware of their governance responsibilities.
- Oversee achievement of the Trusts mandatory training requirement across the division.
- Work with teams to ensure compliance with incident reporting is taking place and support with any educational needs that may arise.
- Ensure all learning and actions are being discussed and disseminated from floor to Board.
Audit Responsibilities:
- Work in conjunction with a designated group of clinicians and specialist nurses to make recommendations designed to eliminate or reduce risk and help facilitate the identified changes in practice.
- To foster and encourage an environment of clinical audit, acting as a facilitator for audits in conjunction with the clinical leads across the Division.
- Take the lead on producing reports for the local governance and quality meetings.
- Work with the divisional team to ensure CENARG audits and guidelines are reviewed.
Professional Responsibilities:
- Maintain own professional registration.
- Act as a role model, maintaining and upholding high standards of professional behaviour.
- Be an effective leader of change, embedding a culture of continuous quality improvement, innovation and use of technology that meets the changing needs of patients.
- Maintain a flexible approach to working.
General responsibilities
To support the department and organisation by carrying out any other duties that reasonably fit within the broad scope of a job of this grade and type of work.
Person Specification
Qualifications
- Registered qualification ie. RN AHP
- Governance training ie. PSIRF
- working towards a MSC
- Management or risk qualification
Experience
- experience of chairing safety reviews
- Experience of PSIRF framework and fundamentals of governance and patient experience
- worked in governance role previously
attitudes and behaviours
- Flexible in their attitudes and behaviours to support team working and delivery of objectives
- take pride in their team
- passion for excellence
- patients first
Knowledge and skills
- Strong understanding of a responsiveness to the complexities and dynamics of the healthcare environment
- Clear understanding of the current NHS issues and initiatives pertaining to Clinical Governance and practice
- Understanding and insight into the challenges of addressing the Clinical Governance/Quality agenda
- You are able to communicate effectively to ensure high standards of care, treatment, service or support as appropriate to your role
- People management skills, including leadership, decision making, negotiating, influencing and persuading skills
- able to use complex data and databases and knowledge of datix process
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.
Ashford & St. Peter’s Hospitals NHS Foundation Trust
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