Role Overview

To own quality, regulatory compliance, and governance across all Serencroft homes: acting as the named lead for CQC and other regulatory relationships, including registration of new acquisitions; leading clinical governance and quality improvement across the group; leading the response to serious safeguarding, complaints, and regulatory escalation matters; keeping policy current against regulatory change; running a full annual KLOE-aligned compliance inspection at each home; and providing the Board with assurance through governance reporting, a group risk and quality register, and cross-site trend analysis. Line manages the Compliance Officer and Business & Compliance Support Officer, who retain their current duties and hours. Provides senior clinical leadership across the group's nursing workforce, setting and assuring clinical standards and competency frameworks for all Registered Nurses; and leads monthly one-to-one performance and KPI review meetings with each Home Manager. To step in the Home Manager role where the Home Manager is absent, with relocation as per the business needs.

Monday to Friday, full-time — hours to be confirmed, with flexibility for site travel and occasional out-of-hours regulatory or safeguarding response.

Key Responsibilities

Regulatory & CQC Relationship

·       Act as the named lead for CQC correspondence, and inspection responses across the group.

·       Maintain current working knowledge of CQC regulations, guidance, and enforcement approach; brief the Head of Operations on regulatory changes affecting the group.

·       Represent Serencroft in formal regulatory engagement, supporting the Nominated Individual as required.

·       Lead CQC registration applications for new acquisitions and newly registered locations, including Statement of Purpose, registered manager applications, and liaison with CQC through to registration confirmation.

Safeguarding

·       Lead the response to serious safeguarding concerns across all homes, coordinating multi-agency and social worker involvement through to closure.

·       Represent the provider at Safeguarding Adult Reviews and Serious Case Reviews.

·       Oversee the safeguarding/DoLS referral tracking maintained by the Compliance Officer, ensuring timely escalation of serious cases.

·       Act as deputy safeguarding lead for the organisation, providing cover and additional capacity for serious or concurrent concerns.

Clinical Governance & Quality Assurance

·       Lead oversight of clinical governance across all homes, including falls, medication safety, pressure ulcer prevention, infection prevention and control, end-of-life care, and clinical risk management.

·       Analyse group-wide clinical quality indicators and identify emerging themes, risks, and learning opportunities.

·       Lead investigations and thematic reviews arising from serious incidents, safeguarding concerns, complaints, and regulatory feedback.

·       Ensure lessons learned are embedded into practice across all services through action plans, training, and governance forums.

·       Set and assure clinical competency standards for Registered Nurses across the group, including skills assessment and clinical supervision frameworks.

·       Provide expert clinical guidance to Home Managers and nursing teams on complex clinical decision-making, including end-of-life care, tissue viability, and deteriorating resident escalation.

Clinical Leadership & Nursing Workforce

·       Act as the senior clinical authority for nursing practice across the group, setting and monitoring clinical standards for all Registered Nurses.

·       Lead a group-wide clinical competency and CPD framework for nursing staff, incorporating skills assessment, clinical supervision, and development planning.

·       Ensure Registered Nurses maintain NMC registration and Code compliance; oversee revalidation support and manage fitness-to-practise referrals where required.

·       Oversee medicines management and controlled drug governance across the group, including resolution of controlled drug discrepancies and escalation of urgent medication safety concerns.

·       Lead clinical incident review and root-cause analysis for serious adverse clinical events, ensuring learning is embedded into nursing practice.

·       Chair a group Clinical Governance Forum bringing together Home Managers and senior nursing staff.

·       Provide clinical sign-off on care planning documentation and clinical policy content, working alongside the Compliance Officer.

Quality Improvement

·       Lead continuous quality improvement programmes across the group.

·       Support homes to achieve and maintain Good and Outstanding CQC ratings.

·       Benchmark performance across homes using internal and external quality indicators.

·       Facilitate the sharing of best practice and lessons learned across services.

·       Monitor home action plans through to completion and challenge barriers to sustained improvement.

Policy & Governance

·       Own and sign off core compliance policies (safeguarding, medicines, infection prevention, health & safety), ensuring they reflect current legislation and regulatory guidance. Data protection/DSPT policy sits with HR.

·       Lead policy amendments in response to regulatory change, inspection findings, or incident learning — moving policy ownership from oversight-only to full authorship and approval.

·       Maintain the group's annual policy review cycle, working with the existing central document repository.

Trend Analysis & Reporting

·       Consolidate the Compliance Officer's monthly per-home audit findings into a single cross-site trend report covering falls, medication errors, safeguarding, and infection control.

·       Produce a quarterly governance report to the Head of Operations and Board summarising compliance status, key risks, and improvement actions across the group.

·       Identify recurring patterns across homes and lead the corrective response, rather than leaving this to individual site-level audits.

Home Manager Performance & KPI Management

·       Lead monthly one-to-one performance and KPI review meetings with each Home Manager, covering quality, safeguarding, clinical, and compliance metrics.

·       Track Home Manager KPI performance over time, identifying trends and escalating sustained underperformance to the Head of Operations.

·       Support Home Managers to set objectives and performance improvement plans arising from KPI review, and monitor progress to closure.

Governance & Board Assurance

·       Develop and maintain a group-wide quality and compliance dashboard.

·       Maintain the organisational governance calendar and regulatory compliance framework.

·       Produce Board Assurance reports highlighting key risks, actions, and performance trends.

·       Maintain a Group Risk and Quality Register with oversight of mitigating actions.

·       Develop qualitative performance measures including resident, relative, and workforce feedback.

Complaints & Whistleblowing

·       Own escalated and serious complaints through to closure, including Ombudsman-referred cases.

·       Act as decision-making owner for whistleblowing and speak-up concerns (the Business & Compliance Support Officer remains first point of intake and logging).

Regulatory Escalation & Incident Management

·       Act as the organisational lead for significant regulatory events, inspections, serious safeguarding concerns, and major incidents.

·       Coordinate organisational responses to enforcement activity, Warning Notices, and provider concerns.

·       Deputise for the Head of Operations in relation to quality, compliance, and safeguarding matters as required.

Audit Follow-Through

·       Ensure audit findings raised by the Compliance Officer are actioned by Registered Managers, escalating non-closure to the Head of Operations.

·       Conduct spot-check or deep-dive audits at homes with recurring or serious findings.

Annual Compliance Inspection

·       Lead a full annual compliance inspection at each home, structured against CQC's five Key Lines of Enquiry (Safe, Effective, Caring, Responsive, Well-led), independent of the Compliance Officer's routine monthly audit cycle.

·       Produce a formal inspection report per home benchmarking evidence against each KLOE, with a Board-ready summary of ratings risk and required actions.

·       Agree and track a time-bound action plan with each Registered Manager arising from the inspection, reporting progress to the Head of Operations.

Workforce Governance

·       Provide oversight of safer recruitment compliance.

·       Monitor professional registrations, DBS compliance, and workforce governance indicators.

·       Support compliance with sponsorship and international recruitment requirements where applicable.

·       Monitor supervision, appraisal, and mandatory training compliance trends across the group.

·       Own the group's Care Workforce Pathway and clinical training strategy, aligning to relevant sector standards.

·       Lead oversight of clinical digital systems rollout (e.g. eMAR, digital care planning) across the group, ensuring clinical benefit realisation and adoption.

External Clinical & Commissioning Relationships

·       Represent Serencroft with NHS/ICB commissioners on clinical funding and commissioning matters, including continuing healthcare, funded nursing care, and clinical ancillary funding.

·       Lead group-wide infection prevention and control (IPC) assurance, liaising with UKHSA and local health protection teams as required.

·       Sit on interview panels for Home Manager and senior clinical recruitment, contributing competency-based clinical assessment.

·       Co - Chair the group Lunch & Leadership Circle, setting the agenda and driving follow-through on actions across Home Managers.

People Management

·       Line manage the Compliance Officer and Business & Compliance Support Officer: supervision, workload allocation, and development.

·       Identify and flag capacity gaps as the group scales, including through any further acquisitions.

·       Provide professional/clinical leadership to Registered Nurses across the group on a matrix basis, working through Home Managers' direct line management.