The following are the core responsibilities of the Governance Manager:
1. Support the Partners, Management, and staff to understand performance and implement changes to policy and practices.
2. Develop systems to understand performance within the organization.
3. Support the practice team in utilizing systems to understand how the team and/or practice is performing.
4. Maintain an in-depth understanding of CQC and its implications on the practice.
5. Signpost staff to guidance and advice on policies and CQC standards.
6. Create and ensure the most up-to-date unified policies and associated documents are accessible and used appropriately.
7. Promote and share best practices with the team.
8. Support the production of performance and quality reports as required.
9. Ensure best practices are followed in maintaining both professional and clinical standards.
10. Undertake compliance audits across the whole practice.
11. Oversee a program of audits and surveys that support and evidence measures of improvement (e.g., complaints, significant events, patient surveys).
12. Coordinate an annual audit and quality assurance visit schedule in collaboration with the management team (e.g., Infection control, CQC preparedness, safeguarding).
13. Undertake pre-audit research and collate data to prepare for audits and identify areas of interest.
14. Conduct Quality and Compliance Audits in line with regulatory, contractual, and organizational requirements (e.g., mock CQC).
15. Record, analyze, and report findings from audits and quality reviews to the partnership and management team.
16. Produce SMART action plans in line with audit and review findings, supporting practice continuous improvement.
17. Raise any non-compliance issues and risk issues to the Business Manager.
18. Source appropriate training providers and evaluate their performance to ensure they meet the learning and development needs of staff.
19. Ensure learning opportunities meet the requirements of CQC standards.
20. Provide support to the practice team to ensure regulatory compliance across the practice.
21. Support preparation for CQC and any other external inspections including audit completion.
22. Lead change and continuous improvement initiatives, ensuring implementation and continuous monitoring are in place.
23. Coordinate the review and updating of all practice policies and procedures working closely with the wider management team.
24. Support the Business Manager with the compilation of practice reports and the practice development plan.
25. Support the practice with the development, implementation, and embedding of an efficient business continuity plan.
26. Keep abreast of governance changes and bring back any actions required.
27. Keep abreast of CQC changes and provide feedback to the management team.
28. Review CQC KLOEs and provide an overview and feedback to the management team.
29. Attend and contribute to all relevant meetings both internally and externally.
30. Arrange agendas, minutes, and action notes for the practice meetings.
31. Liaise at external meetings as required.
32. Always ensure compliance with the relevant legislative acts.
33. Ensure Data Controllers and Data Processors carry out their respective tasks in accordance with extant legislation.
34. Provide guidance and ensure all breaches are managed appropriately, reported as per extant guidance, and lessons learned identified.
35. Support in the SEA annual review process for the practice.
36. Support and coordinate projects within the practice.
37. Lead the annual audit program for the practice, holding staff accountable for actions required and raising any concerns.
38. Support the Business Manager and Building Manager with Health and Safety requirements, ensuring practice compliance.
39. Manage the practice alerts system, keeping a clear and concise record that is accessible to the management team at any time.
40. Overview safeguarding and GSF processes ensuring that practice is meeting requirements.
41. Work closely with the IT manager and wider practice team to ensure compliance with Information Governance and GDPR systems.
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