Job summary We are seeking a Towards Outstanding Regulatory Compliance Improvement Leadto join our team. Band 7 £46,148 - £52,809 per annum, full time 37.5 hour per week. You will articulate and demonstrate a commitment to ongoing patient and staff safety by building excellent relationships with the clinical and governance staff and leaders on the frontline. This role is to give focus on supporting core services to achieve Outstanding Regulatory Compliance, to accomplish this there needs to be plenty of energy and drive in QI and Innovation, aligned to the regulatory key lines of enquiry. This role willsupport the delivery and development of Trust wide continuous improvement, by taking a specific lead on driving quality improvement and innovation within services with a key focus on achieving 'outstanding' ratings from the Trusts regulators and you will work collaboratively with key teams and services throughout the Trust to critically analyse levels of assurance and compliance against regulated requirements, provide specialist advice, guidance and where required; challenge, whilst actively leading teams and services to 'outstanding' regulated compliance. Main duties of the job To provide expert and specialist input into the development and delivery of the Trust quality assurance board work plan. This will include supportingTrust wide announced and unannounced quality assurance visit's and quality assurance audits and reviews; analysing and interpreting a complex range of information and data and to lead the formulation of improvement plans and trajectories to ensure that there is continual focus throughout all Trust services to achieve 'outstanding' regulatory compliance. To facilitate sessions/workshops at various Trust level and Directorate Groups/Committees to motivate and influence continual improvement, whilst providing skilled and expert advice around regulated compliance requirements. To provide high quality reports which triangulate data and demonstrate the monitoring and compliance required to provide assurance to all necessary internal and external bodies. Actively drive, promote and support innovation/quality improvement programmes with clear alignment to 'outstanding' characteristics in line with regulatory criteria (i.e. KLOES for CQC or Ofsted four key judgement categories). Bring insights to help identify and unblock barriers to Improvement to the Trust's quality assurance board and provide leadership to the Directorate senior teams to develop a culture of high-quality governance within the organisation and ensuring the regulatory landscape is understood and there are clear trajectories to achieving 'outstanding' service status. About us As a Trust we remain bold and ambitious with plans for both service and system collaborative transformation over the coming years to improve the health and wellbeing of our local people through high quality care. We pride ourselves onensuring our team has their wellbeing put first and as such provide a range of wellness opportunities including flexible working. We are committed to the Greener NHS national ambition to becoming the world's first 'carbon net zero' national health system by 2045 (Greener NHS (england.nhs.uk). As part of this, sustainability is embedded in our strategy as one of our four key enablers. In order to deliver on this commitment, we recognise that we need a workforce that is as passionate as we are about achieving these goals, for the benefit of our service users, workforce, local communities and the planet alike. For 2024/2025, we have launched our "Proud to be Green" engagement campaign which is aligned to the targets set out in our Green Plan. As a Trust, you can be assured that we will commit to supporting you in working towards our net zero ambitions, set out in our Green Plan, through our sustainability programme". The Trust is committed to ensuring that a diverse workforce is representative and inclusive at all levels. We would very much welcome applications from all under-represented groups including women, people with disabilities, people from global majority backgrounds, and those from the lesbian, gay, bi and trans communities. Date posted 24 October 2024 Pay scheme Agenda for change Band Band 7 Salary £46,148 to £52,809 a year per annum Contract Permanent Working pattern Full-time, Flexible working, Home or remote working Reference number 232-COR-6588614 Job locations Based working from home but meetings/visits to Harplands Hospital/Lawton House & possibly other bases Hilton Road Stoke-on-Trent ST4 6TH Job description Job responsibilities To lead the promotion of compliance/regulation, and the quality governance agenda across the organisation. To provide expert knowledge and training to help build an understanding of, support for, and action in, quality Improvement, innovation and compliance monitoring as a means of improving the performance and decision-making within the Trust. Keep up to date with regulatory new inspection regimes (e.g. CQC, NHSE, Ofsted etc.) for Mental Health & Learning Disability services and to interpret any changes in the context of quality improvement programmes and initiatives to ensure alignment is maintained to outstanding characteristics of the regulatory bodies. To compare and analyse all Trust wide improvements, aligning these to the regulatory domains (i.e. Safe, effective, caring, Responsive & Well Led for CQC) and provide expert opinion regarding any gaps, required areas of focus and to oversee remedial actions, whilst ensuring robust reporting via relevant Trust groups and committees. To have a Trust wide overview of all service self-assessments (Heat maps) and provide expert analysis and sensitive challenge to ensure there is evidence to support where compliance is reported to be achieved / excelling. To develop and deliver programs of work and training to clinical and non-clinical staff in order to assist and to apply leadership skills which will influence and motivate services to undertake compliance/governance related activities and strive towards outstanding services in every area of the Trust, using a variety of working methods. To lead the development and monitoring process for compliance work/action plans/trackers which focus on achieving outstanding services, ensuring that robust assurance is provided and regularly reported to Trust Board/ Committees/Groups. This involves critical analysis and where appropriate challenge to services to ensure robust assurance is in place. To be highly self-motivated and to autonomously manage and prioritise workload; making independent decisions about next steps / improvement requirements within services. Provide professional challenge and where appropriate; take pro-active improvement action to maintain compliance with all key regulatory domains throughout the Trust, ensuring that concerns / barriers are escalated in a timely manner and are also reported via the Trusts Quality Assurance Board. To provide clinical leadership on the programme of announced and unannounced quality visits, and quality assurance audits so that all Trust services can identify any concerns and provide specialist advice which will ensure that concerns are addressed and improvement trajectories towards outstanding are in place. To lead the development and implementation of robust outcome reports from evidence reviews related to the Care Quality Commission registration requirements and ensure any exception reports with areas of improvement have a clear trajectory of achieving outstanding services. To work closely with colleagues in communications and engagement, taking a lead on ensuring messaging is consistent, comprehensive and effective and clearly represents our ambition to be outstanding in all that we do and how we do it. Take responsibility for maintaining the upkeep of the Trust Live QI reporting system to ensure all Towards Outstanding quality improvement initiatives maintain momentum with dedicated QI support and guidance where required. Where necessary ensure that action plans from external visits are monitored via relevant Trust committees locally, collating evidence of implementation and compliance, with clear trajectories towards achieving outstanding services. To provide expert advice and training to services around quality improvement methodology and actively encourage Quality Improvement initiatives, ensuring they are aligned to all core CQC Services and referenced against the relevant Key Line of Enquiry. To be responsible for the monitoring and the delivery of CQC towards Outstanding improvement plans throughout the Trust, providing assurance to Quality Assurance Board. Support Bi-weekly Quality Assurance Board meetings and take responsibility to promote effective engagement with the Directorate leads and Heads of Departments to ensure services have sufficient knowledge and understanding of regulatory requirements and Quality improvement methodologies. Lead monthly meetings with Directorate Leads to review towards outstanding improvement plans and RAG rating of actions - ensuring that robust assurance is in place and can be reported on. Take responsibility to escalate any concerns regarding regulatory compliance to the Trusts Senior Leadership Team. To ensure that reports presented to Trust Board/other Committees are of a high quality and provide robust assurance, with clear trajectories of achieving outstanding service, Work with all levels of staff throughout the Trust - including the Matrons and Service Managers, Executive Leads and Directorate leads. Ensure regular "horizon scanning" to identify changes to existing standards and assist in identifying innovations and improvements in other organisations and areas of nationally showed cased best practice. Actively create opportunities to engage with patients and carers as part of quality assurance and towards outstanding activities. To ensure that all standards set by external agencies e.g. Care Quality Commission (CQC), NHS Improvement, Commissioners etc. are implemented within the Trust, ensuring the Trust is up to date with knowledge regarding current requirements and has processes in place to support achievement of such. Ensure that all required governance policies, protocols, procedures, and strategies are in place, up to date and are evidence based, this includes proactively monitoring for changes in national/local guidance (incl. NICE) and keeping the Policy Review Group abreast of any changes that may impact on Trust-Wide Policies. To lead the review of Trust wide policies,to ensure that they are current, reflect national guidance and current legislation and are compliant with relevant Trust wide standards. Assess the impact of new policies on CQC compliance and comment on draft policies to ensure the authors are aware of the impact. To deputise for the Quality Improvement Manager in their absence and where appropriate take responsibility for the Quality Improvement Teams financial budget. Key Relationships: The role will receive line management from the Trusts Quality Improvement Lead, who will also provide guidance and supervision in quality improvement methodologies. Other key relationships are: - The Trusts corporate governance team, with a particular alignment to the Trusts Quality Assurance and Improvement Manager, where close, partnership working will be essential to the success of the Trusts outstanding regulated compliance. The operational services team leads and senior leadership teams. Job description Job responsibilities To lead the promotion of compliance/regulation, and the quality governance agenda across the organisation. To provide expert knowledge and training to help build an understanding of, support for, and action in, quality Improvement, innovation and compliance monitoring as a means of improving the performance and decision-making within the Trust. Keep up to date with regulatory new inspection regimes (e.g. CQC, NHSE, Ofsted etc.) for Mental Health & Learning Disability services and to interpret any changes in the context of quality improvement programmes and initiatives to ensure alignment is maintained to outstanding characteristics of the regulatory bodies. To compare and analyse all Trust wide improvements, aligning these to the regulatory domains (i.e. Safe, effective, caring, Responsive & Well Led for CQC) and provide expert opinion regarding any gaps, required areas of focus and to oversee remedial actions, whilst ensuring robust reporting via relevant Trust groups and committees. To have a Trust wide overview of all service self-assessments (Heat maps) and provide expert analysis and sensitive challenge to ensure there is evidence to support where compliance is reported to be achieved / excelling. To develop and deliver programs of work and training to clinical and non-clinical staff in order to assist and to apply leadership skills which will influence and motivate services to undertake compliance/governance related activities and strive towards outstanding services in every area of the Trust, using a variety of working methods. To lead the development and monitoring process for compliance work/action plans/trackers which focus on achieving outstanding services, ensuring that robust assurance is provided and regularly reported to Trust Board/ Committees/Groups. This involves critical analysis and where appropriate challenge to services to ensure robust assurance is in place. To be highly self-motivated and to autonomously manage and prioritise workload; making independent decisions about next steps / improvement requirements within services. Provide professional challenge and where appropriate; take pro-active improvement action to maintain compliance with all key regulatory domains throughout the Trust, ensuring that concerns / barriers are escalated in a timely manner and are also reported via the Trusts Quality Assurance Board. To provide clinical leadership on the programme of announced and unannounced quality visits, and quality assurance audits so that all Trust services can identify any concerns and provide specialist advice which will ensure that concerns are addressed and improvement trajectories towards outstanding are in place. To lead the development and implementation of robust outcome reports from evidence reviews related to the Care Quality Commission registration requirements and ensure any exception reports with areas of improvement have a clear trajectory of achieving outstanding services. To work closely with colleagues in communications and engagement, taking a lead on ensuring messaging is consistent, comprehensive and effective and clearly represents our ambition to be outstanding in all that we do and how we do it. Take responsibility for maintaining the upkeep of the Trust Live QI reporting system to ensure all Towards Outstanding quality improvement initiatives maintain momentum with dedicated QI support and guidance where required. Where necessary ensure that action plans from external visits are monitored via relevant Trust committees locally, collating evidence of implementation and compliance, with clear trajectories towards achieving outstanding services. To provide expert advice and training to services around quality improvement methodology and actively encourage Quality Improvement initiatives, ensuring they are aligned to all core CQC Services and referenced against the relevant Key Line of Enquiry. To be responsible for the monitoring and the delivery of CQC towards Outstanding improvement plans throughout the Trust, providing assurance to Quality Assurance Board. Support Bi-weekly Quality Assurance Board meetings and take responsibility to promote effective engagement with the Directorate leads and Heads of Departments to ensure services have sufficient knowledge and understanding of regulatory requirements and Quality improvement methodologies. Lead monthly meetings with Directorate Leads to review towards outstanding improvement plans and RAG rating of actions - ensuring that robust assurance is in place and can be reported on. Take responsibility to escalate any concerns regarding regulatory compliance to the Trusts Senior Leadership Team. To ensure that reports presented to Trust Board/other Committees are of a high quality and provide robust assurance, with clear trajectories of achieving outstanding service, Work with all levels of staff throughout the Trust - including the Matrons and Service Managers, Executive Leads and Directorate leads. Ensure regular "horizon scanning" to identify changes to existing standards and assist in identifying innovations and improvements in other organisations and areas of nationally showed cased best practice. Actively create opportunities to engage with patients and carers as part of quality assurance and towards outstanding activities. To ensure that all standards set by external agencies e.g. Care Quality Commission (CQC), NHS Improvement, Commissioners etc. are implemented within the Trust, ensuring the Trust is up to date with knowledge regarding current requirements and has processes in place to support achievement of such. Ensure that all required governance policies, protocols, procedures, and strategies are in place, up to date and are evidence based, this includes proactively monitoring for changes in national/local guidance (incl. NICE) and keeping the Policy Review Group abreast of any changes that may impact on Trust-Wide Policies. To lead the review of Trust wide policies,to ensure that they are current, reflect national guidance and current legislation and are compliant with relevant Trust wide standards. Assess the impact of new policies on CQC compliance and comment on draft policies to ensure the authors are aware of the impact. To deputise for the Quality Improvement Manager in their absence and where appropriate take responsibility for the Quality Improvement Teams financial budget. Key Relationships: The role will receive line management from the Trusts Quality Improvement Lead, who will also provide guidance and supervision in quality improvement methodologies. Other key relationships are: - The Trusts corporate governance team, with a particular alignment to the Trusts Quality Assurance and Improvement Manager, where close, partnership working will be essential to the success of the Trusts outstanding regulated compliance. The operational services team leads and senior leadership teams. Person Specification Qualifications Essential Knowledge of statistics /information analysis and the use of information across the NHS acquired through degree or equivalent plus additional specialist knowledge acquired through training and relevant experience to Master's degree level or equivalent. Intermediate qualification or demonstrable experience in the use of Microsoft Office Applications Demonstrable experience of working within a healthcare governance setting (NHS or Private healthcare), with knowledge of the following: -Governance, -regulation, quality standards (including CQC) Comprehensive understanding and knowledge of external assessment or regulation. In the NHS Desirable Qualification in Quality Improvement, Patient safety, Governance, etc. or working towards Evidence of leading or active involvement in a quality improvement programme or leading innovation and / or change leadership skills. Experience of evaluating 'evidence' against prescribed standards for a range of assessments and demonstrable experience of working within a governance arena expereince Essential Demonstrable experience of working within a healthcare governance setting (NHS or Private healthcare), with knowledge of the following: - Governance, - regulation, quality standards (including CQC). Comprehensive understanding and knowledge of external assessment or regulation in the NHS Desirable Experience of evaluating 'evidence' against prescribed standards for a range of assessments Expereince, knowledge and skills Desirable Evidence of leading or active involvement in a quality improvement programme or leading innovation and / or change leadership skills. Person Specification Qualifications Essential Knowledge of statistics /information analysis and the use of information across the NHS acquired through degree or equivalent plus additional specialist knowledge acquired through training and relevant experience to Master's degree level or equivalent. Intermediate qualification or demonstrable experience in the use of Microsoft Office Applications Demonstrable experience of working within a healthcare governance setting (NHS or Private healthcare), with knowledge of the following: -Governance, -regulation, quality standards (including CQC) Comprehensive understanding and knowledge of external assessment or regulation. In the NHS Desirable Qualification in Quality Improvement, Patient safety, Governance, etc. or working towards Evidence of leading or active involvement in a quality improvement programme or leading innovation and / or change leadership skills. Experience of evaluating 'evidence' against prescribed standards for a range of assessments and demonstrable experience of working within a governance arena expereince Essential Demonstrable experience of working within a healthcare governance setting (NHS or Private healthcare), with knowledge of the following: - Governance, - regulation, quality standards (including CQC). Comprehensive understanding and knowledge of external assessment or regulation in the NHS Desirable Experience of evaluating 'evidence' against prescribed standards for a range of assessments Expereince, knowledge and skills Desirable Evidence of leading or active involvement in a quality improvement programme or leading innovation and / or change leadership skills. 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. UK Registration Applicants must have current UK professional registration. For further information please see NHS Careers website (opens in a new window). Additional information 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. UK Registration Applicants must have current UK professional registration. For further information please see NHS Careers website (opens in a new window). Employer details Employer name North Staffordshire Combined Healthcare Trust Address Based working from home but meetings/visits to Harplands Hospital/Lawton House & possibly other bases Hilton Road Stoke-on-Trent ST4 6TH Employer's website https://www.combined.nhs.uk/working-together/join-our-team/ (Opens in a new tab)