Clinical Excellence Lead

Key Responsibilities

1. Clinical Leadership & Daily Standards

• Deliver visible, proactive clinical leadership every day.

• Lead safe, high-quality clinical practice aligned with CHG standards and external

professional frameworks.

• Provide structured, accurate daily nursing handovers to ensure clarity, risk

awareness and prioritisation.

• Role-model professionalism, clinical judgement, empathy and accountability.

2. Direct Clinical Practice (“In the Numbers”)

• Work directly alongside nurses and care partners delivering clinical and personal

care.

• Complete wound care, clinical reviews, monitoring, interventions and long-term

condition management.

• Ensure clinical care is consistent, dignified and aligned with personalised goals and

wellbeing outcomes.

3. Line Management of Registered Nurses

• Provide direct line management, supervision, capability oversight and pastoral

support.

• Ensure clinical competence, safe administration practices and consistent

professional standards.

• Complete “Our Suite” HR processes for all direct reports, including support,

progression and accountability.

4. Embedding #FindYourEvelyn (ACB Programme)

• Lead the #FindYourEvelyn Anticholinergic Burden (ACB) pathway, ensuring:

o completion of ACB assessments

o identification of moderate/high ACB scores

o timely follow-up reviews

o GP and pharmacy involvement

o evidence-based reduction planning

o clear documentation of all decisions, rationale and outcomes in Nourish

o involvement of families where appropriate

• Ensure ACB data feeds into the Governance Workbook and drives improvement.

• Use ACB findings to actively reduce clinical risk and avoid preventable hospital

admissions.

5. Specialist Clinical Pathway Oversight

• Provide oversight of core clinical pathways including:

o diabetes

o MUST assessments and nutrition

o hydration and fluid balance

o wound care and pressure injury prevention

o continence and catheter care

o respiratory conditions and oxygen

o pain management and PRN reviews

o behaviour support and ABC monitoring

• Ensure pathways are evidence-based, clearly documented and reviewed routinely.

6. Clinical Governance, Risk Management & Safety

• Lead clinical governance and ensure all risks are identified, escalated, documented

and tracked.

• Ensure compliance with MCA, DoLS and Court of Protection frameworks, embedding

best-interest processes.

• Maintain accurate oversight of clinical risks within the Governance Workbook.

• Lead or support internal governance meetings as required.

7. Deterioration Management & Escalation

• Ensure effective use of NEWS2, RESTORE2 or equivalent tools.

• Lead sepsis escalation approaches and ensure staff recognise triggers.

• Ensure escalation plans are understood by the full MDT.

• Maintain low avoidable hospital admissions through timely intervention and

monitoring.

8. Safeguarding & Root Cause Analysis

• Identify safeguarding concerns and escalate without delay.

• Undertake Root Cause Analysis (RCA) for clinical incidents and embed actions.

• Support safeguarding investigations as directed by senior leadership or external

agencies.

• Disseminate learning to improve practice across teams.

9. Behaviour, Mental Capacity & DoLS Compliance

• Oversee behaviour plans and ensure consistent monitoring of distressed

presentations.

• Ensure mental capacity assessments are completed, reviewed and appropriate.

• Lead best-interest decision making with full rationale documented.

• Ensure DoLS conditions are actioned, monitored and communicated daily.

10. Medication Safety, Homely Remedies & Covert Administration

• Lead impeccable medication governance including:

o ordering

o stock control

o storage

o reconciliation

o controlled drugs

o destruction

• Ensure Homely Remedies documentation, authorisation and recording is complete

and compliant.

• Ensure Covert Medication applications are fully completed with:

o best-interest decisions

o GP/pharmacy authorisation

o risk assessments

o care plans and supporting documentation

• Complete daily MAR chart sampling for accuracy and safe practice.

• Ensure self-administering residents are competency assessed and monitored.

• Ensure thickening agents are stored safely yet accessible as required.

11. Infection Prevention & Antibiotic Stewardship

• Sustain low infection rates through strong IPC practice and oversight.

• Complete IPC audits, walkarounds and escalation actions.

• Track antibiotic usage and promote antimicrobial stewardship.

• Ensure infection control updates and safety notices are actioned.

12. Documentation & Nourish Excellence

• Ensure care plans and risk assessments are robust, personalised and clinically

accurate.

• Ensure all clinical documentation is updated in real time and inspection-ready.

• Audit documentation routinely and provide targeted feedback.

13. Reporting, KPI Monitoring & Governance

• Prepare clinical reports as requested by the Head of Clinical Excellence.

• Track and act on all clinical KPIs including:

o falls

o wounds

o hydration

o nutrition

o behaviours

o infections

o medication errors

o hospital admissions

• Ensure all KPI actions and data feed into the Governance Workbook with evidence of

improvement.

14. Digital Clinical Intelligence

• Monitor digital alerts, weight trends, hydration prompts, bowel monitoring and

other clinical indicators within Nourish.

• Identify emerging patterns early and escalate proactively.

• Use digital dashboards to influence care planning and risk management.

15. Education, Coaching & Capability Building

• Provide clinical coaching, education sessions and reflective learning.

• Identify training needs and escalate for formal training where required.

• Build confidence and capability across the nursing and care workforce.

16. External Liaison (for ALL Residents)

• Engage with GPs, district nurses, mental health teams, therapists, discharge teams,

tissue viability and external specialists.

• Ensure every resident benefits from timely clinical review and appropriate referrals.

17. End-of-Life Care Leadership

• Deliver exceptional, compassionate end-of-life care.

• Ensure anticipatory medications, comfort plans and symptom management.

• Provide emotional support to families during decline and at critical moments.

18. Dining Experience & Clinical Alignment

• Ensure safe, consistent IDDSI levels, swallow guidance, fluid consistency and

nutritional risk management.

• Liaise with the Resident Experience Manager to ensure mealtime safety and dignity.

19. Emergency Preparedness & Response

• Oversee emergency equipment and emergency planning.

• Lead clinical responses during urgent incidents and embed learning.

20. Medicines Governance Reviews

• Lead quarterly medication governance reviews with pharmacy partners.

• Ensure findings and action plans feed into the Governance Workbook.

21. Admission & Discharge Clinical Safety

• Ensure new residents receive complete clinical onboarding including baseline

observations, risk assessments and ACB scoring.

• Ensure safe clinical discharge processes, including medication reconciliation and

transfer summaries.

22. Clinical Representation in Complaints & Investigations

• Provide accurate clinical information for complaints, safeguarding enquiries, coronial

investigations and CQC feedback.

• Ensure all findings are documented with clarity, evidence and professionalism.

23. Outcome-Focused Clinical Reviews (OCRs)

• Complete structured clinical outcome reviews for complex cases, repeated incidents

or deterioration concerns.

• Ensure learning informs care planning and team practice.

24. Workforce Planning Input

• Provide clinical insight for workforce planning, skill mix reviews and development

needs.

• Work collaboratively with the Culture & Engagement Manager to ensure clinical and

cultural priorities align.

25. Transformation, Innovation & Best Practice

• Act as an ambassador for CHG’s clinical strategy and transformation agenda.

• Support group-wide improvement programmes led by the Head of Clinical

Excellence.

• Share best practice and clinical learning across CHG.