University Hospitals of Leicester NHS Trust
We have an exciting opportunity for a motivated and exceptional Compliance Manager. The Compliance Manager will be responsible for monitoring compliance to support the quality and CQC regulatory workstreams across University Hospitals of Leicester. The post holder will work alongside the Head of Quality Assurance and be responsible for monitoring compliance to support the Quality, CQC, and regulatory workstreams in the Trust.
The Compliance Manager will provide leadership in the ongoing review and triangulation of information and assurance in relation to our assurance framework and new quality strategy. This will include working with key stakeholders across the trust to gain assurance and gather evidence in line with the CQC Quality Statements and regulations under the health and social care act. The post holder will work with ward leaders to implement the ward assurance framework and provide detailed analysis in reports to monitor compliance.
This post is an ideal opportunity for someone with a passion for improving quality and care in an acute hospital setting.
We are looking for someone with expertise and understanding of the CQC regulatory platform and has experience of delivering a programme of work at pace and to a high standard to achieve key goals and targets.
Main duties of the job
1. Collate evidence and triangulate assurance for the Trust's RI to Good Assurance Framework.
2. Lead the development and delivery of internal quality assurance (QA) programmes.
3. Support the development of improvement plans, monitoring progress.
4. Provide vision for QA processes, interpreting and translating regulation into an understandable format for staff.
5. Produce and/or coordinate cyclical, routine, periodic, and ad hoc reports.
6. Ensure the smooth functioning of the RI to Good Steering group.
7. Support the implementation and reporting of the Quality Strategy.
8. Work with the Head of Quality Assurance and QA team to support clinical quality and governance issues, ensuring risks are managed, and that changes are implemented to promote continuous improvement and sharing of good practice.
9. Participate in different workstreams as they develop and be responsible for new workstreams within QA and the Quality Strategy, including overseeing the delivery of multiple projects and workstreams, change activities, and embedding new skills and ways of working on behalf of staff and patients.
10. The post holder will need to be flexible in accordance with the scope of the work undertaken to ensure that real benefits to public, patients, and staff are delivered.
About us
Our new strategy, developed with the support and feedback of colleagues, patients, and partners, is our compass for the next seven years (2023-2030).
We have four primary goals:
* High-quality care for all,
* Being a great place to work,
* Partnerships for impact, and
* Research and education excellence.
And we will embed health equality in all we do - taking active steps to reduce the avoidable differences in healthcare that some people face, working in partnership with communities.
This is an exciting moment as we look to the future with clarity on what we already do well and where we need to focus our energies to make an even bigger difference for the people we serve.
Job responsibilities
1. Be responsible for developing and updating CQC related staff information (including booklets, webpage etc.).
2. Deploy a transformational, can-do approach bringing corporate quality and compliance to the forefront of service needs.
3. Interpret and analyze national, regional, and local regulations and policy in relation to compliance and briefing senior managers and frontline staff on organizational implications and requirements.
4. Keep current with, and contribute to new developments in clinical quality governance and compliance in line with the best of national practices.
5. Triangulate intelligence from various sources, such as audits, reviews, claims, coroners, incidents, patient experience, etc.
6. Collaborate with colleagues to implement a multi-professional approach to improving compliance across the organization.
7. Monitor and maintain a central corporate register for capturing details of and tracking progress against recommendations made in relation to compliance inspections, inquiries, national reports, and others as required.
8. Monitor and assure compliance with reports issued by external agencies.
9. Prepare and collate update reports to regulators as required, including visit preparations, timetables, schedules, and ad-hoc requests.
10. Work with colleagues to meet the needs of the regulatory requirements.
11. Develop and implement internal monitoring/assurance systems, working with colleagues to ensure timely, complete, accurate information.
12. Be responsible for the RI to Good Steering Group, including forward planning, agendas, action logs, calling for papers, and minute writing to ensure accurate and smooth functioning of meetings.
13. Implement robust systems of work to ensure that feedback is responded to promptly, effectively, and cohesively.
14. Prepare verbal, written, and visual information timely and to a high standard of accuracy, reliability, and readability, appropriate for a wide range of audiences and without the need for senior editing.
15. Lead the writing of technical material in corporate quality and regulation including Policies, Procedures, Quality Impact Assessments, financial, and cost improvement information.
16. Lead on Trust self-assessment against national quality and regulatory standards and sector best practice.
17. Clinical knowledge is essential for assessment of risks, gaps, mitigation, applying best practice, and triangulation of data.
18. Effectively harness the use of technology for the job portfolio in line with the service needs.
19. Be responsible for maintaining the Quality Assurance webpages and ensure information as appropriate is shared Trust wide.
20. Be able to assimilate and synthesize information from and into reports that ensure the information is clear and understandable.
21. Quality assure any regulatory evidence provided by the wider organization prior to submissions.
22. Prepare information for regulatory visits such as Care Quality Commission.
23. Work with other leads/managers in Quality Assurance to ensure our aims and objectives are collectively delivered, with good working with peers so we work in a joined-up manner; supporting the wider team to meet the needs of stakeholders/management.
24. Deputize for the Head of Quality Assurance as required to manage day-to-day CQC enquiries and liaise with service to gather appropriate responses in a timely manner.
Person Specification
Training and Qualifications
* Qualification to Masters level or equivalent experience.
* Evidence of continuous professional development.
* Professional registration appropriate for clinical qualification held.
* Recognised leadership qualification.
* Recognised project manager qualification.
* Experience of working in the NHS or other healthcare setting.
* Understanding of quality assurance and compliance monitoring.
* Managing multiple portfolios efficiently and effectively.
* Experience of audit and risk management.
* Recent clinical experience in the NHS.
* Experience of using Monday.com.
* Experience of working on quality initiatives with the NHS.
Communication and Relationship Skills
* Ability to work effectively as part of a team.
* Work with a range of stakeholders and colleagues.
Analytical and Judgement Skills
* Problem-solving capabilities.
* Ability to deal with and triangulate multiple data and information sources.
* Excellent IT, numeracy, literacy, and analytical skills.
* Knowledge of statistical techniques and methods.
* Clinical audit and improvement skills in a healthcare setting.
Skills
* Knowledge of current NHS priorities and strategies.
* Knowledge of the CQC regulatory platform and methodologies.
* Confident in the use of M365 and project management tools.
* Understanding of qualitative data analysis techniques.
Planning and Organisational Skills
* Excellent organizational and time management.
* Able to work under pressure and to tight deadlines.
* Able to work autonomously.
* Long-term planning to meet service needs.
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.
University Hospitals of Leicester NHS Trust
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