Paloma Health - Governance Operations Manager

• Partner with the Registered Manager and Medical Director to ensure all governance topics are mapped, monitored and delivered, so that we can demonstrate Paloma is safe, effective and well-led. • Line manage the Safeguarding team, including: • Setting clear objectives, monitoring KPIs, and building a high-performing team • Support the safeguarding team with operational processes, including case tracking, safeguarding supervision records, and multi-agency liaison. • Make sure safeguarding activity and audit findings, led by the Senior Safeguarding Officer, are reported to the governance meeting. • Drive our governance processes, including: • Setting annual quality priorities • Run our governance forums (including agendas/actions/follow ups) • Producing a monthly integrated quality and safety report for the leadership team • Maintain our organisational risk register, including clear risk owners, controls and review dates, and escalate emerging risks • Manage the day-to-day complaints process: logging, acknowledgement, investigation, response and learning, within agreed timeframes. • Drive our patient safety and incident management processes, including: • Manage the day-to-day incident and risk reporting process: logging, triage, response and closure, identifying themes and trends, and reporting them to the governance meeting. • Manage Paloma’s Patient Safety Incident Response Framework • Coordinate learning responses (e.g. after-action reviews, thematic reviews and patient safety incident investigations), and track actions to completion. • Ensure the Duty of Candour is met, and that CQC statutory notifications are submitted on time. • Drive our clinical audit and effectiveness, including • Run an annual clinical audit programme aligned to NICE guidance (CG128 autism in under 19s; NG87 ADHD), covering areas such as record keeping, consent and waiting-list safety. • Coordinate the audit cycle: schedule audits with clinical leads, collate results, track actions to completion, and organise re-audits to show improvement. • Work with the Learning & Development Team so that audit, incident and complaint findings become targeted training. • Ensure clear policies and document control, including: • Own the policy and SOP library (clinical and non-clinical, including information governance), with version control, review dates, ratification and staff sign-off. • Make sure every policy is current, reflects how we actually work, and is understood by the team. • Run our CQC compliance processes, including: • Act as the internal operational lead for compliance with CQC regulations and the quality statements of the single assessment framework. • Maintain an up-to-date evidence library, run mock inspections and gap analyses, and track improvement actions. • Support the Registered Manager and nominated individual with their regulatory duties. • Lead preparation for CQC inspections and deliver post-inspection action plans. • Own our information governance approach: • Act as Paloma's internal Information Governance Lead, supporting the Caldicott Guardian and SIRO, including managing data breaches. • Manage the relationship with our external Data Protection Officer, liaising with them as needed. • Act as the escalation point for subject access requests where Care Coordination teams need input, so responses are complete and on time. • Foster a culture of openness and learning: • Foster a culture of openness, accountability, collaboration and continuous improvement across the whole Paloma team. • Make sure staff know how to raise concerns safely, including through our Freedom to Speak Up Guardian, and share learning through regular safety and quality bulletins. • Lead on innovation in governance, such as incident management systems and quality dashboards. • Success metrics for this role include: • Incidents and complaints acknowledged, reviewed and closed within agreed timeframes. • 100% of CQC statutory notifications and Duty of Candour requirements met on time. • All clinical policies and SOPs are kept in date. • The annual clinical audit programme is delivered, with actions closed on time. • Risk register reviewed monthly, with no overdue actions on high risks. • CQC evidence library complete and current, and an inspection outcome of Good or better.