MAIN DUTIES AND RESPONSIBILITIES: To support the Executive team in all matters pertaining to governance. To ensure that all governance policies and procedures are reviewed as required and are fully implemented across all sites, with particular focus on complaints, incidents and data security. To prepare the agenda and produce minutes as required for governance meetings. To ensure compliance with the annual Data Security and Protection Toolkit. Liaison with our Data Protection Officer (DPO) on all relevant matters pertaining to governance. Monitor changes with legislation and ensure changes are implemented across the PCN Any other duties as required by the Execs team CQC Compliance Support the Executive Manager with the preparation and submission of CQC reports, ensuring all documentation is accurate and submitted within required timelines. Monitor compliance with CQC standards, identifying areas for improvement and implementing necessary changes, utilising the CQC trackers on Agilio TeamNet as the evidence framework (e.g. research/estates/clinical evaluation reports). Supporting the Executive Lead and the Partner lead with CQC compliance across the PCN. Monitoring changes to CQCs Regulatory Framework, ensuring that the SAHC Executive Team is kept informed and understands the implications. Support processing CQC applications e.g. change of registered manager, change of premises. Supporting the Executive manager in producing/monitoring any improvement action plans needed following CQC monitoring/inspection. Maintaining an ongoing relationship with Agilio TeamNet to ensure the CQC Tracker tool remains fit for purpose. Coordinating the creation, review and update of SAHC policies on Agilio TeamNet, assigning appropriate ownership on an ongoing basis. Overseeing the Incident and Complaint management, reporting areas of concern to the Executive, as well as proposing solutions. Complaints Oversee the complaints process, ensuring all patient complaints are handled promptly, professionally, and in accordance with established procedures. To develop, line manage and be an integral part of the complaints function acting as the first point of contact for practice staff seeking to resolve queries, concerns and complaints. To operate a strict code of confidentiality at all times. To develop and provide support, advice and training to staff through a variety of modalities. To draft and present regular reports. This will require analysis of complex data in order to identify trends or hot spots. Escalation of complaints not dealt with at site level. Support sites with response writing or general queries. Act as organisation first point of contact for complaints. Liaison with medical defence. Enable effective and efficient handling of cross-agency complaints; work in partnership with provider organisations, the local authority, local and national organisations, and staff from other NHS Organisations as required. To organise, attend and oversee the minute taking of formal complaint meetings, where appropriate. To support learning from complaints through training, continuous quality improvement and the development of an open culture. Coordinate/manage response to enquiries from the Parliamentary and Health Service Ombudsman. Maintain accurate records of all complaints and actions taken, ensuring confidentiality and compliance with data protection regulations. Freedom of Information and Access to Records Support sites in delivering Freedom of Information, Environmental Information Regulations, and Access to Records procedures. Coordinate/manage the response to enquiries from the Information Commissioners Office. Provide advice, support, clarification and assistance to staff; assisting those who are contributing to requests for information to ensure that the information that is provided meets statutory requirements. Identify trends in information requests and establish whether information requested could be more readily available in the future. Incident Management To support SAHC in delivering a high quality and integrated incident management reporting. To be responsible for incident management analysis, and the production and presentation of regular reports informally as well as to formal governance meetings. To support sites in the investigation and reporting of any incidents as required. To be responsible for the management of the incident reporting system, ensuring that SAHC staff are supported with any technical system issues, as required. To provide advice, support and training as required, on the use of the incident management reporting system. To produce written guidance and deliver training as required on incident management. Clinical Governance Contribute to the development and maintenance of sound clinical governance and risk management. Support the development/implementation on any new ways of working/policies that need to be introduced across the SAH. Support SAHC in operating a quality assurance but no blame culture that adheres to best practice around incident reporting and whistle blowing. Engagement with Patients, Internal and External Stakeholders Develop the Communications strategy for the practice and ensure the websites and social media platforms are up to date and on brand, and that the practice regularly updates patients and staff on service delivery and improvement initiatives. Initiate, develop and maintain excellent third-party relationships e.g. with CCGs, NHSE Area Teams, sub-contractor providers, patient groups, local community health teams and other stakeholders to grow, maintain and support service and performance delivery. To ensure patient surveys are undertaken, analysed and action plans are developed and acted upon