Clinical Excellence Lead
Purpose of the Role
The Clinical Excellence Lead is the senior on\-site clinical leader, responsible for ensuring
safe, evidence\-based, person\-centred and wellbeing\-focused clinical care across the home.
They provide visible clinical leadership, deliver hands\-on practice, oversee governance and
risk management, and ensure exceptional clinical communication every day.
They directly line manage Registered Nurses, lead the clinical handover structure, drive the
\#FindYourEvelyn ACB programme, reduce avoidable hospital admissions, embed medication
safety, uphold documentation standards in Nourish, and ensure all residents—regardless of
whether they are nursing or residential—receive timely, appropriate and well\-
communicated clinical oversight.
This role is a cornerstone of CHG’s clinical governance model and operates as the clinical
anchor for the home.
About The Role
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
- Provide structured, accurate daily nursing handovers to ensure clarity, risk
- Role\-model professionalism, clinical judgement, empathy and accountability.
- Work directly alongside nurses and care partners delivering clinical and personal
- Complete wound care, clinical reviews, monitoring, interventions and long\-term
- Ensure clinical care is consistent, dignified and aligned with personalised goals and
3\. Line Management of Registered Nurses
- Provide direct line management, supervision, capability oversight and pastoral
- Ensure clinical competence, safe administration practices and consistent
- Complete “Our Suite” HR processes for all direct reports, including support,
4\. Embedding \#FindYourEvelyn (ACB Programme)
- Lead the \#FindYourEvelyn Anticholinergic Burden (ACB) pathway, ensuring:
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
5\. Specialist Clinical Pathway Oversight
- Provide oversight of core clinical pathways including:
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.
- Lead clinical governance and ensure all risks are identified, escalated, documented
- Ensure compliance with MCA, DoLS and Court of Protection frameworks, embedding
- Maintain accurate oversight of clinical risks within the Governance Workbook.
- Lead or support internal governance meetings as required.
- 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
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
- Disseminate learning to improve practice across teams.
- Oversee behaviour plans and ensure consistent monitoring of distressed
- 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.
- Lead impeccable medication governance including:
o stock control
o storage
o reconciliation
o controlled drugs
o destruction
- Ensure Homely Remedies documentation, authorisation and recording is complete
- Ensure Covert Medication applications are fully completed with:
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.
- 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.
- Ensure care plans and risk assessments are robust, personalised and clinically
- Ensure all clinical documentation is updated in real time and inspection\-ready.
- Audit documentation routinely and provide targeted feedback.
- Prepare clinical reports as requested by the Head of Clinical Excellence.
- Track and act on all clinical KPIs including:
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
14\. Digital Clinical Intelligence
- Monitor digital alerts, weight trends, hydration prompts, bowel monitoring and
- Identify emerging patterns early and escalate proactively.
- Use digital dashboards to influence care planning and risk management.
- 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.
- Engage with GPs, district nurses, mental health teams, therapists, discharge teams,
- Ensure every resident benefits from timely clinical review and appropriate referrals.
- 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.
- Ensure safe, consistent IDDSI levels, swallow guidance, fluid consistency and
- Liaise with the Resident Experience Manager to ensure mealtime safety and dignity.
- Oversee emergency equipment and emergency planning.
- Lead clinical responses during urgent incidents and embed learning.
- Lead quarterly medication governance reviews with pharmacy partners.
- Ensure findings and action plans feed into the Governance Workbook.
- Ensure new residents receive complete clinical onboarding including baseline
- Ensure safe clinical discharge processes, including medication reconciliation and
22\. Clinical Representation in Complaints \& Investigations
- Provide accurate clinical information for complaints, safeguarding enquiries, coronial
- Ensure all findings are documented with clarity, evidence and professionalism.
- Complete structured clinical outcome reviews for complex cases, repeated incidents
- Ensure learning informs care planning and team practice.
- Provide clinical insight for workforce planning, skill mix reviews and development
- Work collaboratively with the Culture \& Engagement Manager to ensure clinical and
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
- Share best practice and clinical learning across CHG.
- Experience completing ACB assessments (\#FindYourEvelyn) with reductions evidenced
- Impeccable medication safety standards
- Strong, confident and accountable
- Experience creating safe, personalised care plans and risk assessments
- Experience with end\-of\-life care
About The Company
At Constantia Healthcare Group, we believe great care starts with great people. We are a values\-driven organisation supporting individuals with age\-related needs and complex care requirements, ensuring the people we care for remain at the centre of everything we do. Our teams are supported, respected and encouraged to grow, because we know that when our colleagues thrive, the quality of care we deliver
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