Maidenhead Primary Care Network

CQC Compliance Manager

Information:

This job is now closed

Job summary

We are seeking a CQC Compliance Manager to play a lead role in delivering a wide range of business, data submission, transformation and improvement initiatives across the primary care locality and provide strategic transformation support and leadership.

The role is well supported by an engaged Practice Management Group and Clinical Leaders for strategic areas of development.

Main duties of the job

As the CQC Compliance Manager you will work with Partners, Practice Manager and wider practice team, ensuring understanding of and compliance with all aspects of the practices regulatory obligations. You will co-ordinate the collection and monitoring of evidence to provide assurance of compliance with CQC requirements.

The Quality and Compliance Manager will support a programme of audit, review and continuous improvement to ensure that the PCN can be CQC complaint and support application as required. We aim to obtain an outstanding rating and continues to provide excellent patient care.

To work proactively with Partners, Practice Manager, Salaried GPs, Nurses and administration teams to support the effective delivery of quality, performance, regulatory and compliance functions across the organisation.

The post holder will implement agreed policies and consider the introduction of new services to ensure the quality and efficiency of services we deliver.

The post holder is responsible to the PCN Manager, but will also liaise closely with all PCN partners.

About us

Maidenhead Primary Care Network, is a group of 9 GP Practices with a proven track record in working both together and with our local strategic partners to deliver at scale projects to the 80000 patient population of Maidenhead in Berkshire.

We are fortunate to have a wonderful workforce of both Clinical and non Clinical colleagues working together with our Practice staff to deliver new care models to our patients.

We have an established leadership team, governance group and are supported by an engaged and enthusiastic Practice Management Group and Clinical Leaders for strategic areas of development.

We look forward to you joining us on our continued journey

Details

Date posted

02 November 2023

Pay scheme

Other

Salary

Depending on experience

Contract

Permanent

Working pattern

Part-time, Flexible working

Reference number

A5556-23-0042

Job locations

St. Marks Hospital

112 St. Marks Road

Maidenhead

Berkshire

SL6 6DU


Job description

Job responsibilities

To work proactively with the PCN management team, Clinical Director, Partners, Practice Manager, Salaried GPs, Nurses and administration teams to support the effective delivery of quality, performance, regulatory and compliance functions across the organisation.

The post holder will implement agreed policies and consider the introduction of new services to ensure the quality and efficiency of services we deliver.

The post holder is responsible to the PCN Manager, but will also liaise closely with all the Clinical Director, Directors, partners, Nurse Lead and Patient Services, Finance & IT Managers.

Quality and Performance Responsibilities:

Oversee the development and implementation of Maidenhead PCN strategy, policies and procedures in relation to: data entry and collection, compliance, regulation and performance monitoring, Including QOF and IIF targets

Support Partners, Practice Manager and the wider PCN team to understand and meet local, national and organisational targets in relation to compliance, regulation, performance and information governance.

Develop and deliver a focussed and relevant compliance framework to enable the PCN to meet CQC and contractual inspection and audit requirements.

Ensure the implementation of appropriate systems, policies and procedures in relation to: data collection, compliance, regulation, ICB strategy, performance monitoring and data protection.

Delivery of the in-house training required for managers and staff to ensure the appropriate levels of engagement and support are in place for effective compliance.

Contribute to the preparation and updating of Practice Development Plans and oversee the implementation of the aims and objectives in relation to Quality and compliance.

Foster an environment within the team that supports staff development and encourages ideas and takes account of staff opinions.

To support Safeguarding with administrative support in ensuring safeguarding processes are followed and information requests are responded within timeframes set.

Data

Work with colleagues to ensure accurate data is available to underpin effective performance management, compliance and risk management, supporting continuous improvement of PCN activities.

Have oversight of data quality across the PCN and support teams to achieve good data quality providing managers with expert guidance as required.

Work with the senior management team to support the development of tools and processes to enable Amicus Health to measure and report against targets set.

Incident Management

Oversee the PCN's incident management systems, liaising with staff to ensure all incidents are recorded and processed in line with policy.

Oversee data and produce management reports on incidents as requested

Encourage a culture of continuous learning through incidents by establishing appropriate frameworks and assisting managers in implementing them

Information Governance

Working closely with the senior management team, ensure compliance with information governance standards across the PCN

Ensure completion of the PCNs annual Information Governance Toolkit submission.

Acting as the PCN's lead for information governance and data protection issues and submitting a range of data returns

To have responsibility for data protection issues across the PCN with the support of the PCN's Data Protection lead

To maintain and submit the Data Security Protection Toolkit return on behalf of the PCN

Policy and Procedure

Support colleagues to understand and implement organisational standards, policies and procedures, including where appropriate the delivery of training and advice sessions.

Administer policy management system, coordinating the policy review schedule, dissemination and implementation procedures.

Co-ordinate the PCN's policy management system ensuring policy review schedule is adhered to and overseeing ratification and dissemination process

Quality Assurance

Lead a programme of annual internal inspections across the PCN, reporting back to the PCN management team and Practice Managers on compliance rating and suggested areas for development

General

Perform any other duties consistent with the broad objectives of the post.

To lead on the recruitment and retention of data and prescriptions staff.

Confidentiality

In the course of seeking treatment, patients entrust us with, or allow us to gather, sensitive information in relation to their health and other matters. They do so in confidence and have the right to expect that the post-holder will respect their privacy and act appropriately.

In the performance of the duties outlined in this Job Description, the post-holder may have access to confidential information relating to patients and their carers, practice staff and other healthcare workers. They may also have access to information relating to the practice as a business organisation. All such information from any source is to be regarded as strictly confidential.

Information relating to patients, carers, colleagues, other healthcare workers or the business of the practice may only be divulged to authorised persons in accordance with the practice policies and procedures relating to confidentiality and the protection of personal and sensitive data.

Health and Safety

To lead on Health and Safety and ensure compliance across the organisation.

The post-holder will assist in promoting and maintaining their own and others health, safety and security as defined in the practice Health and Safety Policy, to include:

Using personal security systems within the workplace according to practice guidelines.

Identifying the risks involved in work activities and undertaking such activities in a way that manages those risks.

Making effective use of training to update knowledge and skills.

Using appropriate infection control procedures, maintaining work areas in a tidy and safe way and free from hazards.

Actively reporting health and safety hazards and infection hazards immediately when recognised.

Keeping own work areas and general areas clean and assisting in the maintenance of general standards of cleanliness consistent with the scope of the post-holders role.

Undertaking annual infection control training.

Reporting potential risks identified.

Job description

Job responsibilities

To work proactively with the PCN management team, Clinical Director, Partners, Practice Manager, Salaried GPs, Nurses and administration teams to support the effective delivery of quality, performance, regulatory and compliance functions across the organisation.

The post holder will implement agreed policies and consider the introduction of new services to ensure the quality and efficiency of services we deliver.

The post holder is responsible to the PCN Manager, but will also liaise closely with all the Clinical Director, Directors, partners, Nurse Lead and Patient Services, Finance & IT Managers.

Quality and Performance Responsibilities:

Oversee the development and implementation of Maidenhead PCN strategy, policies and procedures in relation to: data entry and collection, compliance, regulation and performance monitoring, Including QOF and IIF targets

Support Partners, Practice Manager and the wider PCN team to understand and meet local, national and organisational targets in relation to compliance, regulation, performance and information governance.

Develop and deliver a focussed and relevant compliance framework to enable the PCN to meet CQC and contractual inspection and audit requirements.

Ensure the implementation of appropriate systems, policies and procedures in relation to: data collection, compliance, regulation, ICB strategy, performance monitoring and data protection.

Delivery of the in-house training required for managers and staff to ensure the appropriate levels of engagement and support are in place for effective compliance.

Contribute to the preparation and updating of Practice Development Plans and oversee the implementation of the aims and objectives in relation to Quality and compliance.

Foster an environment within the team that supports staff development and encourages ideas and takes account of staff opinions.

To support Safeguarding with administrative support in ensuring safeguarding processes are followed and information requests are responded within timeframes set.

Data

Work with colleagues to ensure accurate data is available to underpin effective performance management, compliance and risk management, supporting continuous improvement of PCN activities.

Have oversight of data quality across the PCN and support teams to achieve good data quality providing managers with expert guidance as required.

Work with the senior management team to support the development of tools and processes to enable Amicus Health to measure and report against targets set.

Incident Management

Oversee the PCN's incident management systems, liaising with staff to ensure all incidents are recorded and processed in line with policy.

Oversee data and produce management reports on incidents as requested

Encourage a culture of continuous learning through incidents by establishing appropriate frameworks and assisting managers in implementing them

Information Governance

Working closely with the senior management team, ensure compliance with information governance standards across the PCN

Ensure completion of the PCNs annual Information Governance Toolkit submission.

Acting as the PCN's lead for information governance and data protection issues and submitting a range of data returns

To have responsibility for data protection issues across the PCN with the support of the PCN's Data Protection lead

To maintain and submit the Data Security Protection Toolkit return on behalf of the PCN

Policy and Procedure

Support colleagues to understand and implement organisational standards, policies and procedures, including where appropriate the delivery of training and advice sessions.

Administer policy management system, coordinating the policy review schedule, dissemination and implementation procedures.

Co-ordinate the PCN's policy management system ensuring policy review schedule is adhered to and overseeing ratification and dissemination process

Quality Assurance

Lead a programme of annual internal inspections across the PCN, reporting back to the PCN management team and Practice Managers on compliance rating and suggested areas for development

General

Perform any other duties consistent with the broad objectives of the post.

To lead on the recruitment and retention of data and prescriptions staff.

Confidentiality

In the course of seeking treatment, patients entrust us with, or allow us to gather, sensitive information in relation to their health and other matters. They do so in confidence and have the right to expect that the post-holder will respect their privacy and act appropriately.

In the performance of the duties outlined in this Job Description, the post-holder may have access to confidential information relating to patients and their carers, practice staff and other healthcare workers. They may also have access to information relating to the practice as a business organisation. All such information from any source is to be regarded as strictly confidential.

Information relating to patients, carers, colleagues, other healthcare workers or the business of the practice may only be divulged to authorised persons in accordance with the practice policies and procedures relating to confidentiality and the protection of personal and sensitive data.

Health and Safety

To lead on Health and Safety and ensure compliance across the organisation.

The post-holder will assist in promoting and maintaining their own and others health, safety and security as defined in the practice Health and Safety Policy, to include:

Using personal security systems within the workplace according to practice guidelines.

Identifying the risks involved in work activities and undertaking such activities in a way that manages those risks.

Making effective use of training to update knowledge and skills.

Using appropriate infection control procedures, maintaining work areas in a tidy and safe way and free from hazards.

Actively reporting health and safety hazards and infection hazards immediately when recognised.

Keeping own work areas and general areas clean and assisting in the maintenance of general standards of cleanliness consistent with the scope of the post-holders role.

Undertaking annual infection control training.

Reporting potential risks identified.

Person Specification

Experience

Essential

  • Applicants must demonstrate the following competencies and or experience to be considered for interview:
  • Staff management including line management, performance management and appraisal
  • Strong leadership and communication skills
  • Good presentation skills
  • Experience of working within General Practice and/or a CQC regulated healthcare or social care setting
  • An ability to manage & prioritise multiple tasks and projects
  • Ability to work without supervision, providing specialist advice to the organisation, working to tight and often changing timescales
  • An ability to work quickly and effectively
  • Use of initiative and an ability to solve problems
  • Knowledge of relevant legislation
  • Excellent IT skills
  • Decision making
  • Ability to work independently and as part of a team
  • Resilience
  • Demonstrable commitment to and focus on quality, promotes high
  • standards to consistently improve patient outcomes
  • Actively develops themselves and others.
  • Used to working in a busy environment.
  • Adaptability, flexibility and ability to cope with uncertainty and change.

Desirable

  • Experience of working in Primary Care or GP practice is most preferred.
Person Specification

Experience

Essential

  • Applicants must demonstrate the following competencies and or experience to be considered for interview:
  • Staff management including line management, performance management and appraisal
  • Strong leadership and communication skills
  • Good presentation skills
  • Experience of working within General Practice and/or a CQC regulated healthcare or social care setting
  • An ability to manage & prioritise multiple tasks and projects
  • Ability to work without supervision, providing specialist advice to the organisation, working to tight and often changing timescales
  • An ability to work quickly and effectively
  • Use of initiative and an ability to solve problems
  • Knowledge of relevant legislation
  • Excellent IT skills
  • Decision making
  • Ability to work independently and as part of a team
  • Resilience
  • Demonstrable commitment to and focus on quality, promotes high
  • standards to consistently improve patient outcomes
  • Actively develops themselves and others.
  • Used to working in a busy environment.
  • Adaptability, flexibility and ability to cope with uncertainty and change.

Desirable

  • Experience of working in Primary Care or GP practice is most preferred.

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.

Employer details

Employer name

Maidenhead Primary Care Network

Address

St. Marks Hospital

112 St. Marks Road

Maidenhead

Berkshire

SL6 6DU


Employer's website

https://www.maidenheadpcn.nhs.uk/ (Opens in a new tab)

Employer details

Employer name

Maidenhead Primary Care Network

Address

St. Marks Hospital

112 St. Marks Road

Maidenhead

Berkshire

SL6 6DU


Employer's website

https://www.maidenheadpcn.nhs.uk/ (Opens in a new tab)

Employer contact details

For questions about the job, contact:

Sukhi Hersey

sukhi.hersey1@nhs.net

Details

Date posted

02 November 2023

Pay scheme

Other

Salary

Depending on experience

Contract

Permanent

Working pattern

Part-time, Flexible working

Reference number

A5556-23-0042

Job locations

St. Marks Hospital

112 St. Marks Road

Maidenhead

Berkshire

SL6 6DU


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