Quality Assurance Compliance Manager

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Job overview

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 a 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
• Collate evidence and triangulating assurance for the Trusts RI to Good Assurance Framework,
• Lead the development and delivery of internal quality assurance( QA) programmes
• Support the development of improvement plans, monitoring progress
• Provide vision for QA processes , interpreting and translating regulation into an understandable format for staff
• Produce and/or co-ordinate cyclical, routine, periodic and ad hoc reports
• Ensure the smooth functioning of RI to Good Steering group
• Support the implementation and reporting of the Quality Strategy
• 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.
• 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 work streams, change activities and embedding new skills and ways of working on behalf staff and patients.
• 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.

Working for our organisation

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.

Our strategy is underpinned by new values and we will work to ensure they are an everyday reality for all:

• we are compassionate,
• we are proud,
• we are inclusive, and
• we are one team

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.

About the University Hospitals of Leicester NHS Trust:

http://www.leicestershospitals.nhs.uk/aboutus/work-for-us/current-vacanc...

Detailed job description and main responsibilities
• Be responsible for developing and updating CQC related staff information (including booklets, webpage etc.)
• Deploy a transformational, can-do, approach bringing corporate quality and compliance to the forefront of service needs
• Interpretation and analysis of national, regional and local regulations and policy in relation to compliance and briefing senior managers and frontline staff on organisational implications and requirements.
• Keep current with, and contribute to new developments in clinical quality governance and compliance in line with the best of national practices
• Triangulate intelligence from various sources, such as audits, reviews, claims, coroners, incidents, patient experience etc.
• Collaborate with colleagues to implement a multi-professional approach to improving compliance across the organisation
• Monitor and maintain a central corporate register for capturing details of and tracking progress against recommendations made in relation to compliance inspections, enquiries, national reports and others as required.
• Monitor and assure on compliance with reports issued by external agencies
• Prepare and collate update reports to regulators as required, including visit preparations, timetables, schedules, ad-hoc requests. Work with colleagues to meet the needs of the regulatory requirements
• Develop and implement internal monitoring/assurance systems, working with colleagues to ensure timely, complete, accurate information
• 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
• Implement robust systems of work to ensure that feedback is responded to promptly, effectively, and cohesively
• 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 need for senior editing
• Lead the writing of technical material in corporate quality and regulation including Policies, Procedures, Quality Impact Assessments, financial and cost improvement information.
• Lead on Trust self-assessment against national quality and regulatory standards and sector best practice. Clinical knowledge is essential for assessment of risks, gaps, mitigation, applying best practice, and triangulation of data
• Effectively harness use of technology for the job portfolio in line with the service needs
• Be responsible for maintaining the Quality Assurance webpages and ensure information as appropriate is shared Trust wide
• Be able to assimilate and synthesise information from and into reports that ensure the information is clear and understandable
• Quality assure any regulatory evidence provided by the wider organisation prior to submissions
• Be the information governance expert within the quality/regulation services.
• Prepare information for regulatory visits such as Care Quality Commission. Working with colleagues to meet the needs of regulatory requirements in quality.
• Work with other leads/managers in Quality Assurance to ensure our aims and objectives are collectively delivered, with good working with peers so we worked in a joined-up manner; supporting the wider team to meet the needs of stakeholders/management.
• Deputise 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

Essential criteria

• Qualification to Masters level or equivalent experience
• Evidence of continuous professional development

Desirable criteria

• Clinical qualification
• professional registration appropriate for clinical qualification held
• recognised leadership qualification
• recognised project manager qualification

Expereince

Essential criteria

• Experience of working in the NHS or other health care setting
• Understanding of quality assurance and compliance monitoring
• Managing multiple portfolios efficiently and effectively
• Experience of audit and risk management

Desirable criteria

• Recent clinical experience in the NHS
• Experience of using Monday.com
• Experience of working on quality initiatives with the NHS

Communication and relationship skills

Essential criteria

• Ability to work effectively as part of a team
• work with a range of stakeholders and colleagues

Analytical and Judgement skills

Essential criteria

• problem solving capabilities
• ability to deal with and triangulate multiple data and information sources
• Excellent IT, Numeracy , literacy and analytical skills

Desirable criteria

• report writing
• knowledge of statistic techniques and methods
• clinical audit and improvement skills in a health care setting

Skills

Essential criteria

• Knowledge of current NHS priorities and strategies
• Knowledge of the CQC regulatory platform and methodolgies
• confident in the use of M365 and project management tools

Desirable criteria

• understanding of qualitative data analysis techniques

Planning and organisational skills

Essential criteria

• Excellent Organisational and time management
• able to work under pressure and to tight deadlines
• Able to work autonomously
• Long term planning to meet service needs

Additional Information

Please submit your application form without delay to avoid disappointment; we will close vacancies prior to the publishing closing date if we receive a sufficient number of completed application forms.

Please check the email account (including your junk mail) that you supplied as part of your application on a regular basis following the closing date and throughout the recruitment process, as this is how we will communicate with you.

UHL is an equal opportunities employer. We aim to employ a workforce that reflects the diverse communities we serve. We welcome applications from people from all backgrounds who match our job criteria.

Applicants who have a disability and meet the essential criteria for the job will be interviewed if you indicate you wish to be considered under the Guaranteed Interview Scheme. If you require a reasonable adjustment at any stage of the recruitment process please make the recruitment services team aware as soon as possible.

UHL is committed to helping colleagues balance the demands of both their work and personal needs through flexible working arrangements wherever reasonably practicable and subject to service needs.

Disclosure and Barring Service Check

Please note if you are successful in obtaining this position and the post involves regulated activity you will be required to undertake a Disclosure & Barring Service check.

The Trust will pay for the check initially and the money will then be deducted from your salary over a three month period commencing on your first month's payment.

The current price of a check is £38 for an enhanced and £18 for a standard check.

COVID 19 Risk Assessment

Due to the current Covid pandemic we have introduced a staff risk assessment into our pre-employment process. This now forms part of the mandatory pre-employment checks that will be carried out if you receive a conditional offer.

The risk assessment is intended to ensure you are able to safely perform your duties in any of our work areas, and if you have been identified as being particularly vulnerable to coronavirus. Our main aim is to reduce risk and to ensure the safety of all new starters to the Trust as well as current staff, patients and visitors.

If it is identified that you are within a vulnerable category, we will endeavor to make reasonable adjustments to accommodate this through discussions with both Occupational Health and your recruiting manager.

Covid Vaccination Status

Covid-19 vaccination remains the best way to protect yourself, family, colleagues and our patients/service users from the Covid-19 virus. We therefore continue to encourage our current and potential colleagues to get vaccinated.

University Hospitals of Leicester NHS Trust holds the principles of equality, diversity and inclusion at the heart of everything it does and all that it stands for. We are committed to developing a workforce that is representative of the community we serve. We welcome applications from the diverse community of Leicester, Leicester and Rutland, to help deliver healthcare services that meets the needs of our diverse communities.

Employer certification / accreditation badges

Applicant requirements

The postholder will have access to vulnerable people in the course of their normal duties and as such this post is subject to the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (Amendment) (England and Wales) Order 2020 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service to check for any previous criminal convictions.

Documents to download

• Quality Assurance Compliance Manager AFC Band 7 (PDF, 672.3KB)
• Understanding your right to work in the UK (PDF, 1.1MB)
• Employee Benefits (PDF, 578.5KB)