Compliance and Assurance Lead

Job summary

Compliance and Assurance Lead (Band 7, hours, Permanent)

Ashford & St Peters NHS Foundation Trust are seeking an experienced midwife or nurse, with demonstrable knowledge of the clinical governance and patient safety agenda, to join their established and experienced Quality & Safety Team within the Women's Health & Paediatrics Division. In this role, you will be responsible for ensuring compliance with a wide variety of standards and regulations and other national, regional and local requirements.

You will need to be adaptable, able to manage your own workload, responsive to events as they occur and enjoy working as part of a busy team with a passion for quality improvement and a strong desire to improve safety and patient experience.

You will be joining ASPH Maternity Department at a time of exciting change as we embark upon a journey to implement the new national Patient Safety Incident Response Framework (PSIRF) designed to support teams to learn from incidents and support the families and staff involved.

Visits for prospective employees are welcomed.

Please contact Emma Bradley, Maternity and Neonatal Safety Lead () for an informal chat about the role.

Main duties of the job

The post holder will have day-to-day ownership of the Maternity Regulatory requirements including the Care Quality Commission (CQC) standards and regulations, NHS Resolution Maternity incentive scheme(CNST) and other related requirements.

The post holder will develop, implement and monitor strategies to ensure CQC, CNST, Saving Babies Lives (SBL) and other maternity related standards are met. This should be inclusive of supporting incident case reviews, PMRT and ATAIN reviews.

The post holder will monitor the service compliance with NICE guidance and support the oversight of guideline reviews within appropriate timeframes.

The post holder will assist with the development and compliance of local and national clinical audit plans, ensuring there is a robust programme of clinical audit.

Regulatory Maternity and corporate quality initiatives will be joined up internally, and with system partners, so that the Maternity service attains a high performing status with excellent assurance and required the post holder should represent the Trust and the maternity service externally at applicable forums with support from the Perinatal Quality and Safety Lead or with specific delegated responsibility to provide required reports, data, audit outcomes and compliance of regulatory standards and ambitions.

About us

Ashford and St. Peters Hospitals NHS Foundation Trust serves a population of more than 410,000 people living in North-West Surrey, parts of Hounslow and beyond.

Over 3,700 highly trained doctors, nurses, midwives, therapists, healthcare scientists and other support staff make up our workforce, providing a wide range of services across our two hospital sites, Ashford, Surrey and St Peter's, Chertsey, Surrey.

We also run many specialist clinics in the community and local community hospitals and other healthcare facilities.

Our vision is to be one of the best healthcare Trusts in the country. There has never been a better time to join us in the NHS at ASPH. We are committed to providing continuous professional development, staff benefits and flexibility to shape our workforce around our patient care.

This is an exciting time to join our Trust, as we work on the expansion of our theatres at Ashford Hospital and move towards this becoming our dedicated elective centre. We want to create a state-of-the-art centre for excellence for planned surgical procedures; with care delivered by dedicated, specialist teams in a modern and well-equipped environment.

We hope to use this centre to create an environment of learning and to facilitate training of the next generation of our skilled NHS workforce. Our plans are ambitious - why not, come and be a part of our journey.

Adverts may close early, so applicants are encouraged to submit an application as soon as possible.

Job description

Job responsibilities

You will achieve your role through performing work to the highest standards of performance. You will deliver the requirements of the maternity services in respect of regulation, compliance and quality. Regulation incorporates all applicable requirements relating to maternity services including, but not limited to, statutory requirements, other legal requirements, requirements of health regulators such as Care Quality Commission (CQC), NHS Improvement (NHSI), National Health Service Resolution (NHSR) and items recommended by external advisors to the Trust.

The mix of work among areas may change over time, according to service need.

The post holder will assist with the development and compliance of local and national clinical audit plans, and NICE guidance compliance, ensuring there is a robust programme of clinical audit and clinical guideline review in place. Deploy a transformational, can-do, approach to ensuring the services compliance with core areas of quality and where regulation is required. Support the Perinatal Quality and Safety Lead to meet the requirements of the Patient Safety Incident Response Framework (PSIRF) relevant to the job role, specifically oversight of audit and test of effectiveness. Support the Quality & Safety Lead to develop robust mechanisms that enable floor to Board reporting and assurance. Ensure mechanisms are in place to audit key quality metrics in all clinical areas; working with the clinical matrons for each area and other specialist roles to monitor compliance and service improvements. Deliver, and be the expert advisor on, regulation and core corporate quality, and work with colleagues to convert this into practical delivery across the Service. Support the compliance with Perinatal Mortality Review Tool process. Effectively contribute to the Trust and Maternity vision, strategic objectives and key work programmes. Monitor and assure on compliance with reports issued by external agencies. Prepare and collate update reports to regulators including visit preparations, timetables, schedules, clinical performance update reports, ad-hoc requests, and other regulatory submissions externally and internally. Develop and implement internal monitoring/assurance systems to support compliance with the Maternity Incentive Scheme, working with colleagues to ensure the systems provide timely, complete, accurate information and that this is used to drive clinical service improvement. Prepare information for regulatory visits such as Care Quality Commission. Work with colleagues to meet the needs of regulatory requirements. Work with other leads/managers of the service, to ensure aims and objectives are collectively delivered in a joined-up manner. Expertly handle timely, accurate and smooth functioning of relevant service level meetings. This includes organising, minute-taking, monitoring, and other related corporate activities required to meet the needs of the department and those involved. Be an expert minute taker, requiring no re-work of draft minutes. Quality assure on minutes taken by colleagues. Support information associated with external/internal bodies such as CCG, CQC, or other forums as applicable to the role. 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. Lead on service self-assessment against national quality and regulatory standards and sector best practice. Person Specification

Qualifications and Further Training

Essential

Current NMC registration as either Registered Midwife or Registered Nurse Educated to postgraduate level or equivalent (or significant practical experience of regulation and compliance activities including service and process re-design.

Desirable

Quality improvement methodology training and or Project Management qualification ( PRINCE) or equivalent work experience Recent training in an acute Trust in the NHS which demonstrates alignment with this role

Experience

Essential

Previous experience with a Governance / Quality and safety role in an acute setting Experience with implementation of regulatory requirements and change management. Knowledge of Audit methodology and statistical techniques. Participation in clinical audit, QI, including data collection and developing action plans Report writing to a high standard. Experience of administrative processes (could include agendas, scheduling papers, preparing meeting/Committee papers, and administering meetings). Experience reviewing and writing, written material including investigations, reports, papers, data summaries and correspondence to a high standard - commensurate with profile correspondence to be available to the public and external organisations. Experience working autonomously as well as leading, planning and organising work of a team to meet specific deadlines and quality standards. Ability to juggle the requirements of various portfolios effectively. Able to develop project workplans and negotiate, deliver, and monitor these for large projects such as regulatory inspections, audits, peer reviews and comparable projects. Agile manager able to demonstrate how you have handled sensitive complex situations in a pressured environment. Experience of working across professional boundaries to influence and achieve improvement collectively. Clinical experience and knowledge Experience developing and tracking action plans to ensure delivery.

Desirable

Advanced knowledge of IT applications Knowledge of improvement methodologies and how to apply these to Quality and Regulation

Knowledge

Essential

Trust vision, values, strategic objectives and key work programmes A good understanding of the acute NHS sector current topical programmes and national maternity initiatives. Knowledge of maternity terminology. Knowledge of Care Quality Commission standards regarding patient experience and how these should be implemented in practice. A good understanding of the national NHS quality and regulation agenda and initiatives. Knowledge of data protection issues and patient confidentiality. Understanding of cultural and diversity matters and how these can be effectively addressed particularly to benefit service users.

Desirable

Knowledge of improvement methodologies and how to apply these in quality and regulation

Skills

Essential

Clinical audit and improvement skills obtained in an acute health setting. Knowledge & awareness of diversity and human rights as appropriate to your role Able to communicate effectively to ensure high standards of care, treatment, service or support as appropriate to your role, Able to provide a customer focussed service Able to work under pressure, produce work at short notice, and prioritise competing demands Able to work both autonomously and as part of a wider Trust Team. Ability to effectively juggle the requirements of various portfolios. Excellent technical writer of correspondence including reports, investigation responses, and other written information to ensure accurate and correct grammar and content. Competent handling and resolving of investigations. Able to synthesise and interpret information and translate this into a readable report, adapted to the audience as required. Has excellent attention to detail. Ability to practically generate governance, risk, quality and comparable information in a range of ways - templates, guidance documents, standard operating procedures, and policies. Compile and review investigation reports to a high standard Able to generate dashboards, key performance indicators, exception report, analyse and write commentaries. Ability to translate complex clinical information into accessible language. Policy writing and review - practically applying technical guidance into policies. Confident presenting a wide range of information to colleagues in an engaging and effective way. Able to present events/workshops using different media to a variety of audiences. Practical problem-solving experience which has met the expectations of colleagues and stakeholders who use this kind of service - so the recipient gets the correct information in relation to their enquiries Able to validate data and information to demonstrate its reliability and triangulate evidence from differing information sources. Able to positively influence others to make changes Excellent administration and organisational skills and an ability to prioritise and manage time effectively, without supervision. Ability to keep good records and follow relevant procedures.

Desirable

Able to present high quality visual communications material in presentations, brochures, reports using media and other technologies

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