Quality and Compliance Manager

We are currently looking to recruit a Quality and Compliance Manager to work between our three sites. Salary is negotiable depending on experience.

Accountable to: Chief Executive

Responsible to: Chief Executive

The Quality and Compliance manager is a peripatetic  manager who will travel between sites and ensure that Eastleigh Care homes remains CQC Compliant, they are responsible for safety, support and delivery of services, driving the quality strategy and supporting the work of the teams to deliver local high-quality services.    For the first three months will be based at Minehead.

JOB SUMMARY:

As a senior member of the team, the post holder is responsible for leading and driving quality improvement and regulatory compliance to achieve the best service standards and outcomes for patients and Eastleigh Care Homes( ECH)  key responsibilities include:

  • Work with Managers and Directors to lead and develop the quality strategy.
  • Lead/support implementation of the quality strategy plans for quality improvement, quality assurance and related organisational learning.
  • Lead/support delivery of Eastleigh quality accounts with the support of the Operations Director
  • Initiate a Quality and Compliance Committee.
  • Assist in Leading and developing processes and systems to ensure compliance with regulatory bodies and stakeholders which includes best practice
  • Promoting collaboration and transfer of best practice within each of the services
  • Lead quality programmes and projects.
  • Oversee the management and review of policies and procedures ensuring appropriate arrangements and infrastructure is in place.
  • Ensure appropriate policies and procedures are in place to support quality improvement.

KEY RESULTS AREAS

  • To lead and promote quality in the Eastleigh Care Homes through effective leadership
  • Provide Support to the Directors and Registered Managers
  • Evidence of measurable improvements in organisational quality standards, both outcomes and outputs, year on year.
  • Delivery of regulatory requirements and actions, for example CQC action plans.
  • Evidence of quality developments in each of the services
  • Successful delivery across all key responsibilities.
  • Support the Operations Director in moving the Quality and Compliance program forward

MAIN RESPONSIBILITIES

Quality improvement 

  • Lead the implementation, monitoring and review of the Quality Strategy, Quality & Governance Framework and Quality plans in line with ECH objectives and priorities ensuring that they reflect changing legislation and regulations.
  • Ensure the Quality Strategy, Quality & Governance Framework and Quality plans support continuous improvement and the delivery of high standards of care.
  • In collaboration with the Operation Director and Registered Managers and Clinical  leads support the development of Eastleigh Care Homes  programs for quality improvement, including quality priorities and metrics and ensure timely delivery and monitoring for effectiveness and impact on standards of patient and service user care and treatment.
  • Ensure quality improvement and clinical governance techniques and tools are embedded in ECH decision making, planning and performance management processes.
  • Actively engage with internal and external stakeholders to ensure the trust is leading edge in delivering all aspects of Quality Improvement.
  • Co-ordinate the development of quality information published on the website to promote the implementation and delivery of quality improvement plans at local service level.
  • Provide leadership, specialist advice and support to the Board, Senior Managers and staff in relation to developing quality improvement initiatives to deliver leading edge practice that improves people’s experiences of services and leads to better evidence-based outcomes.
  • Lead the development and delivery of quality scorecards/dashboards by working with frontline clinical staff to develop appropriate quality metrics and indicators to promote continuous improvement in the quality of patient care.

 

Compliance and assurance

  • In conjunction with the director of Operations and commissioners agree an appropriate set of quality targets and indicators as part of the annual Contract Quality Schedule.
  • Ensure regulatory requirements in relation to corporate and clinical quality management are met.
  • Review and interpret new national guidance and/or legislation relating to Quality Improvement and identify local implementation for ECH
  • Lead/support the development and publication of the annual Quality Account/Quality Report, ensuring appropriate consultations and involvement with internal and external stakeholders throughout the process.
  • Ensure processes and systems are in place across the organisation to maintain ECH CQC registration, including variations to registration which reflect the changing regulated activities and locations of ECH
  • Ensure appropriate CQC compliance monitoring programmes and processes are in place across ECH Services to be able to evidence registration and ensure awareness of and readiness for external inspection and registration validation.
  • Oversee all external assessments of ECH CQC visits, and ensure recommendations from these are acted upon ECH
  • Oversee the ECH compliance framework relating to the Care Quality Commission, NHSI, Commissioning and other external reviews and accreditation processes including the submission of periodic returns and reports as required.
  • Ensure there are systems in place to co-ordinate monitoring and follow-up of recommendations from internal and external audits
  • Continue to develop the quality assurance model (supported by the quality dashboard) to triangulate data and information to produce a “worry list” (quality concern areas) which is prioritised and addressed by agreed committee action.
  • Work with key internal stakeholders (e.g. performance and information) to improve ward to Board (and vice versa) information and communication, to facilitate Board assurance on key quality and safety areas.

 

Quality and safety committee

  • Manage the ECH Quality & Compliance Committee (Board sub-committee), ensuring there is an annual cycle of business in place to address internal and external reporting requirements, also that there is a high quality agenda, minutes and papers, and regular reports from this group are available to the Board.

 

Policy management

  • Lead the ECH policy management processes, including compliance and governance.
  • Ensure the ECH has arrangements in place for the effective initiation, consultation, approval and continuous review of corporate policies and procedures.

 

People management

  • Role model the values and behaviours both individually and through the team.

 

Financial responsibility

  • Responsibility for managing any departmental budget / approved project implementation costs and benefits delivery, including realising agreed financial savings.

 

Planning and reporting

  • Produce and/or co-ordinate the production of cyclical, routine, periodic and ad hoc analysis, information, data and high-quality reports for ECH Board, Quality & Compliance Committee, ECH Management Board, Executive Directors, managers, frontline staff and other committees as required.
  • Provide expert advice, information and support to senior managers, clinicians and committees on matters relating to quality and compliance and ensure ECH is kept informed of related national strategic issues.

 

Central/Strategic

  • Contribute to the delivery of the ECH objectives on quality, safety and governance and ensure delivery of ECH strategy, our Vision of Excellence.
  • Contribute to the delivery of national standards and external requirements for all aspects of quality.
  • Support Clinical Governance Meetings
  • From ECH perspective, manage the agenda and administrative arrangements for the Commissioners Clinical Quality Review Group (CQRG).
  • Be responsible for managing an annual quality away day.

 

General

  • Contribute to the development and delivery of ECH annual business planning cycle and the Annual Quality & Governance Delivery Plan with priorities and deliverables which support the achievement of the Trusts objectives
  • Staff management, training, development, appraisal and performance and capability management in accordance with ECH policies and procedures
  • Contribute to the design and delivery of quality, risk, governance and compliance training programmes delivered by the Quality & Governance Team.
  • Contribute to the design, implementation and monitoring of internal indicators and metrics which enable ECH to understand and improve its performance in relation to quality, risk, business continuity, safety and compliance.
  • Work with the team to actively learn from other organisations and adopt good practice to improve performance at Moorfields.

 

 

GENERAL DUTIES

  • To comply at all times with the requirements of the Health & Safety regulations under the Health & Safety at Work Act (1974) and to take responsibility for the health and safety and welfare of others in the working environment ensuring that agreed safety procedures are carried out to maintain a safe environment.
  • To comply always with ECH data security policy. Also, to respect confidentiality of information about staff, residents, and health service business and in particular the confidentiality of electronically stored personal data in line with the Data Protection Act.
  • Disclosure Barring (DBS) (formerly CRB) checks are now a mandatory part of the ECH recruitment process for staff who, in the course of their normal duties, have access to patients. ECH aims to promote equality of opportunity for all with the right mix of talent, skills and potential.  Criminal records will be considered for recruitment purposes only when the conviction is relevant.  Having an unspent conviction will not necessarily bar you from employment.  This will depend on the circumstances and background to the offence and the position you have applied for.  ECH is exempt under the Rehabilitation of Offenders Act.  This means the convictions never become “spent” for work which involves access to residents.  Failure to disclose any “unspent” convictions may result in the offer of employment being withdrawn or if appointed could lead to dismissal.  The Disclosure Barring Service (DBS) has published a code of practice for organisations undertaking DBS checks and a copy is available on request.
  • ECH has adopted a security policy to help protect residents, visitors and staff and to safeguard their property. All employees have a responsibility to ensure that those persons using ECH and its service are as secure as possible.
  • It is the responsibility of all ECH employees to fully comply with the safeguarding policies and procedures of ECH. As a ECH employee you must ensure that you understand your role in protecting adults and children that may be at risk of abuse. Individuals must ensure compliance with their safeguarding training.
  • ECH is committed to a policy of equal opportunities. A copy of our policy is available from QCS
  • The ECH operates a no-smoking policy.
  • You should familiarise yourself with the requirements of the ECH policies in respect of the Freedom of Information Act and comply with those requirements accordingly.
  • The role description gives a general outline of the duties of the post and is not intended to be an inflexible or finite list of tasks. It may be varied, from time to time, after consultation with the post holder.
  • It is the responsibility of all employees to ensure that they comply with the trust infection control practises, as outlined in the health Act 2008 and staff must be familiar with the policies in the trusts infection control manual, this includes the “bare below the elbow policy”. Employees must ensure compliance with their annual infection control training.
  • You are responsible for ensuring that all equipment used by Residents is clean / decontaminated as instructed by manufacturers and in line with the infection control / guidelines protocol and policy. It is the responsibility of all employees to ensure compliance with the Health and Social Care Act, 2008, in preventing risk of infections to residents, visitors and other staff within ECH.
  • All staff are required to implement infection control policies and practices, including hand hygiene, waste disposal, staff uniform and occupational health responsibilities, as detailed in the trust intranet.
  • It is the responsibility of all staff to ensure that they have evidence of annual/or otherwise infection control training.
  • All staff are responsible for ensuring that equipment used in the patient environment is cleaned, decontaminated and maintained in line with trust policy.
  • Any other duties as designated by your manager and which are commensurate with the grade.
  1. The Job description is a new position and may change in light of subsequent developments, in consultation with the post holder.Accountable to: Chief ExecutiveResponsible to: Chief ExecutiveThe Quality and Compliance manager is a peripatetic  manager who will travel between sites and ensure that Eastleigh Care homes remains CQC Compliant, they are responsible for safety, support and delivery of services, driving the quality strategy and supporting the work of the teams to deliver local high-quality services.    For the first three months will be based at Minehead.

    JOB SUMMARY:

    As a senior member of the team, the post holder is responsible for leading and driving quality improvement and regulatory compliance to achieve the best service standards and outcomes for patients and Eastleigh Care Homes( ECH)  key responsibilities include:

    • Work with Managers and Directors to lead and develop the quality strategy.
    • Lead/support implementation of the quality strategy plans for quality improvement, quality assurance and related organisational learning.
    • Lead/support delivery of Eastleigh quality accounts with the support of the Operations Director
    • Initiate a Quality and Compliance Committee.
    • Assist in Leading and developing processes and systems to ensure compliance with regulatory bodies and stakeholders which includes best practice
    • Promoting collaboration and transfer of best practice within each of the services
    • Lead quality programmes and projects.
    • Oversee the management and review of policies and procedures ensuring appropriate arrangements and infrastructure is in place.
    • Ensure appropriate policies and procedures are in place to support quality improvement.

    KEY RESULTS AREAS

    • To lead and promote quality in the Eastleigh Care Homes through effective leadership
    • Provide Support to the Directors and Registered Managers
    • Evidence of measurable improvements in organisational quality standards, both outcomes and outputs, year on year.
    • Delivery of regulatory requirements and actions, for example CQC action plans.
    • Evidence of quality developments in each of the services
    • Successful delivery across all key responsibilities.
    • Support the Operations Director in moving the Quality and Compliance program forward

    MAIN RESPONSIBILITIES

    Quality improvement 

    • Lead the implementation, monitoring and review of the Quality Strategy, Quality & Governance Framework and Quality plans in line with ECH objectives and priorities ensuring that they reflect changing legislation and regulations.
    • Ensure the Quality Strategy, Quality & Governance Framework and Quality plans support continuous improvement and the delivery of high standards of care.
    • In collaboration with the Operation Director and Registered Managers and Clinical  leads support the development of Eastleigh Care Homes  programs for quality improvement, including quality priorities and metrics and ensure timely delivery and monitoring for effectiveness and impact on standards of patient and service user care and treatment.
    • Ensure quality improvement and clinical governance techniques and tools are embedded in ECH decision making, planning and performance management processes.
    • Actively engage with internal and external stakeholders to ensure the trust is leading edge in delivering all aspects of Quality Improvement.
    • Co-ordinate the development of quality information published on the website to promote the implementation and delivery of quality improvement plans at local service level.
    • Provide leadership, specialist advice and support to the Board, Senior Managers and staff in relation to developing quality improvement initiatives to deliver leading edge practice that improves people’s experiences of services and leads to better evidence-based outcomes.
    • Lead the development and delivery of quality scorecards/dashboards by working with frontline clinical staff to develop appropriate quality metrics and indicators to promote continuous improvement in the quality of patient care.

     

    Compliance and assurance

    • In conjunction with the director of Operations and commissioners agree an appropriate set of quality targets and indicators as part of the annual Contract Quality Schedule.
    • Ensure regulatory requirements in relation to corporate and clinical quality management are met.
    • Review and interpret new national guidance and/or legislation relating to Quality Improvement and identify local implementation for ECH
    • Lead/support the development and publication of the annual Quality Account/Quality Report, ensuring appropriate consultations and involvement with internal and external stakeholders throughout the process.
    • Ensure processes and systems are in place across the organisation to maintain ECH CQC registration, including variations to registration which reflect the changing regulated activities and locations of ECH
    • Ensure appropriate CQC compliance monitoring programmes and processes are in place across ECH Services to be able to evidence registration and ensure awareness of and readiness for external inspection and registration validation.
    • Oversee all external assessments of ECH CQC visits, and ensure recommendations from these are acted upon ECH
    • Oversee the ECH compliance framework relating to the Care Quality Commission, NHSI, Commissioning and other external reviews and accreditation processes including the submission of periodic returns and reports as required.
    • Ensure there are systems in place to co-ordinate monitoring and follow-up of recommendations from internal and external audits
    • Continue to develop the quality assurance model (supported by the quality dashboard) to triangulate data and information to produce a “worry list” (quality concern areas) which is prioritised and addressed by agreed committee action.
    • Work with key internal stakeholders (e.g. performance and information) to improve ward to Board (and vice versa) information and communication, to facilitate Board assurance on key quality and safety areas.

     

    Quality and safety committee

    • Manage the ECH Quality & Compliance Committee (Board sub-committee), ensuring there is an annual cycle of business in place to address internal and external reporting requirements, also that there is a high quality agenda, minutes and papers, and regular reports from this group are available to the Board.

     

    Policy management

    • Lead the ECH policy management processes, including compliance and governance.
    • Ensure the ECH has arrangements in place for the effective initiation, consultation, approval and continuous review of corporate policies and procedures.

     

    People management

    • Role model the values and behaviours both individually and through the team.

     

    Financial responsibility

    • Responsibility for managing any departmental budget / approved project implementation costs and benefits delivery, including realising agreed financial savings.

     

    Planning and reporting

    • Produce and/or co-ordinate the production of cyclical, routine, periodic and ad hoc analysis, information, data and high-quality reports for ECH Board, Quality & Compliance Committee, ECH Management Board, Executive Directors, managers, frontline staff and other committees as required.
    • Provide expert advice, information and support to senior managers, clinicians and committees on matters relating to quality and compliance and ensure ECH is kept informed of related national strategic issues.

     

    Central/Strategic

    • Contribute to the delivery of the ECH objectives on quality, safety and governance and ensure delivery of ECH strategy, our Vision of Excellence.
    • Contribute to the delivery of national standards and external requirements for all aspects of quality.
    • Support Clinical Governance Meetings
    • From ECH perspective, manage the agenda and administrative arrangements for the Commissioners Clinical Quality Review Group (CQRG).
    • Be responsible for managing an annual quality away day.

     

    General

    • Contribute to the development and delivery of ECH annual business planning cycle and the Annual Quality & Governance Delivery Plan with priorities and deliverables which support the achievement of the Trusts objectives
    • Staff management, training, development, appraisal and performance and capability management in accordance with ECH policies and procedures
    • Contribute to the design and delivery of quality, risk, governance and compliance training programmes delivered by the Quality & Governance Team.
    • Contribute to the design, implementation and monitoring of internal indicators and metrics which enable ECH to understand and improve its performance in relation to quality, risk, business continuity, safety and compliance.
    • Work with the team to actively learn from other organisations and adopt good practice to improve performance at Moorfields.

     

     

    GENERAL DUTIES

    • To comply at all times with the requirements of the Health & Safety regulations under the Health & Safety at Work Act (1974) and to take responsibility for the health and safety and welfare of others in the working environment ensuring that agreed safety procedures are carried out to maintain a safe environment.
    • To comply always with ECH data security policy. Also, to respect confidentiality of information about staff, residents, and health service business and in particular the confidentiality of electronically stored personal data in line with the Data Protection Act.
    • Disclosure Barring (DBS) (formerly CRB) checks are now a mandatory part of the ECH recruitment process for staff who, in the course of their normal duties, have access to patients. ECH aims to promote equality of opportunity for all with the right mix of talent, skills and potential.  Criminal records will be considered for recruitment purposes only when the conviction is relevant.  Having an unspent conviction will not necessarily bar you from employment.  This will depend on the circumstances and background to the offence and the position you have applied for.  ECH is exempt under the Rehabilitation of Offenders Act.  This means the convictions never become “spent” for work which involves access to residents.  Failure to disclose any “unspent” convictions may result in the offer of employment being withdrawn or if appointed could lead to dismissal.  The Disclosure Barring Service (DBS) has published a code of practice for organisations undertaking DBS checks and a copy is available on request.
    • ECH has adopted a security policy to help protect residents, visitors and staff and to safeguard their property. All employees have a responsibility to ensure that those persons using ECH and its service are as secure as possible.
    • It is the responsibility of all ECH employees to fully comply with the safeguarding policies and procedures of ECH. As a ECH employee you must ensure that you understand your role in protecting adults and children that may be at risk of abuse. Individuals must ensure compliance with their safeguarding training.
    • ECH is committed to a policy of equal opportunities. A copy of our policy is available from QCS
    • The ECH operates a no-smoking policy.
    • You should familiarise yourself with the requirements of the ECH policies in respect of the Freedom of Information Act and comply with those requirements accordingly.
    • The role description gives a general outline of the duties of the post and is not intended to be an inflexible or finite list of tasks. It may be varied, from time to time, after consultation with the post holder.
    • It is the responsibility of all employees to ensure that they comply with the trust infection control practises, as outlined in the health Act 2008 and staff must be familiar with the policies in the trusts infection control manual, this includes the “bare below the elbow policy”. Employees must ensure compliance with their annual infection control training.
    • You are responsible for ensuring that all equipment used by Residents is clean / decontaminated as instructed by manufacturers and in line with the infection control / guidelines protocol and policy. It is the responsibility of all employees to ensure compliance with the Health and Social Care Act, 2008, in preventing risk of infections to residents, visitors and other staff within ECH.
    • All staff are required to implement infection control policies and practices, including hand hygiene, waste disposal, staff uniform and occupational health responsibilities, as detailed in the trust intranet.
    • It is the responsibility of all staff to ensure that they have evidence of annual/or otherwise infection control training.
    • All staff are responsible for ensuring that equipment used in the patient environment is cleaned, decontaminated and maintained in line with trust policy.
    • Any other duties as designated by your manager and which are commensurate with the grade.
    1. The Job description is a new position and may change in light of subsequent developments, in consultation with the post holder.