Job summary
CDDFT is looking to recruit a skilled and experienced
governance processional to fulfil the role of Assurance and Compliance Lead.
This is a genuinely Trust-wide role in which you will use your knowledge,
expertise and experience to support colleagues at all levels from ward to Board,
and across a wide range of services, in meeting CQCs Fundamental Standards of
Care and in maintaining high standards of risk management and clinical
governance. By helping colleagues deliver good governance, you will make a real
difference to patient care and gain an excellent understanding of the Trust and
its services. Working to the Assurance and Compliance Manager, you will be an
integral member of a small team engaged in:
Training,
coaching and supporting staff in implementing the Trusts risk management
process
Leading
on implementing and improving systems to monitor compliance with
recommendations from NICE
Operating
and improving quality assurance systems, including analysing and interpreting
data to highlight areas for investigation and learning
Monitoring
compliance with CQC Fundamental Standards of Care
Reporting
to the Trust Board and its Committees.
Main duties of the job
The post-holder will:
- Train, coach, advise and assist staff in implementing the
Trust's risk management procedures
- Operate, and continuously improve, systems for monitoring
compliance with NICE guidelines
- Support a portfolio of care groups and services in
implementing high standards of clincial governance, highlighting issues
requiring attention and providing ongoing support as required
- Develop and maintain working relationships with staff at
all levels from ward to Board and across a range of services to allow the above
duties to be performed effectively.
- Maintain complex data systems, to enable the Trust and its
care groups to understand and improve performance against a range of quality
indicators. This includes undertaking system administration activity and
reconciling data uploads.
- Compilation of detailed reports to the Board, intepreting
complex datasets on risk and quality assurance.
- Monitor and track the implementation of Internal Audit
recommendations and reporting to the Audit Committee on progress.
- Advising staff on CQC Fundamental Standards of Care and
assessment framework and contributing to audits and arrangements in place to
monitor compliance.
About us
If you are being interviewed you must accept an interview slot in the system to continue, even if you have arranged with the manager
You must be able to produce ALL certificates stated essential in the person specification or you will not be able to complete pre-employment checks
We provide hospital services from two acute sites - Darlington Memorial Hospital and University Hospital of North Durham. We have a centre for planned care in Bishop Auckland and provide care from community hospitals in Chester-le-Street, Shotley Bridge, Barnard Castle, Sedgefield and Weardale as well as over 80 other community based settings and providing care in patients' homes.
We particularly welcome applications from disabled and Black, Asian and Minority Ethnic (BAME) candidates as BAME and disabled people are currently under-represented
From April 1 2024 we are unable to offer sponsorship for healthcare roles that do not meet the minimum salary, If you are in the UK on a VISA please ensure you have no restrictions that would prevent you from taking this post.
Full Job Descriptions can be found in the adverts supporting documents
Job description
Job responsibilities
The candidate will:
Take the
lead role in reviewing risk registers routinely and particularly ahead of
Executive risk review meetings providing reports to the Senior Associate
Director of Assurance and Compliance on issues arising and working with risk
owners to resolve issues.
Take the
lead role in undertaking audits of the accuracy of risk registers in each area.
Initially audits will be undertaken at least bi-monthly, and monthly for those
areas requiring intensive support.
Provide
expert advice and training in risk management to senior managers across the
Trust, and maintain and update training documentation and guidance on the risk
management process and the risk management system.
Provide
content on behalf of the Senior Associate Director of Assurance and
Compliance for complete the Quarterly Assurance and Risk report to the Board,
with particular reference to the interpretation and analysis of significant
risks and trends and themes in risk registers.
Completing
monthly reports to the Trusts Integrated Quality and Assurance Committee on a
range of quality indicators and trends, interpreting the information
competently to highlight both assurance and areas for improvement.
Take the
lead role in ensuring that NICE Guidance is being reviewed and implemented
accordingly throughout the Trust. Reviewing the NICE database routinely and
particularly ahead of Care Group Governance meetings at which monthly reports
are provided for information and discussion.
Provide
content to the Head of Assurance and Compliance for quarterly assurance care
group quality and performance review meetings, underlining any anticipated
problems or concerns and highlighting issues for escalation.
Provide
expert support and advice to clinicians and service managers across the Trust,
providing guidance on the NICE process and where issues are identified work
with clinicians to resolve those issues.
For those areas requiring more intensive support, undertake meetings to
provide more concentrated guidance.
Provide
monthly reports of overdue internal audit recommendations to the Senior
Associate Director of Assurance and Compliance and follow up any issues,
agreeing and following through actions with relevant stakeholders.
Complete
quarterly monitoring reports to the Audit Committee on the status of overdue
internal audit recommendations and rates of implementation.
Maintain
the External Visit database, follow up any issues, agreeing and following
through actions with relevant stakeholders and challenge compliance where
necessary. Produce reports according to reporting schedules.
Support
the Head of Assurance and Compliance in communicating and co-ordinating complex
activities to meet standards and expectations set by the Care Quality
Commission (CQC) and to assist the Trust in maintaining its registration, by
completing allocated tasks and discrete projects.
Take an
active role in implementing Trust quality assurance processes focused on
assessing CQC regulatory compliance, at ward, service and Trust level, interpreting
and reporting outcomes to enable care group and service leaders to take
appropriate action and helping to continuously improve these processes.
Undertake
a critical friend role working alongside Care Groups and Corporate
Directorates to develop their assurance, risk management and governance
processes. This will involve constructively challenging existing processes and
facilitating improvement and will require attendance at Care Group meetings. It
will also entail the provision of subject matter expertise.
Plan
training and audit programmes and complex sub-programmes of work to gather
assurance on behalf of the Board and to implement and embed compliance with
regulatory requirements.
Prepare
Care Group exception reports and, for a portfolio of care groups, where
necessary, lead the communication regarding outstanding issues with the
relevant stakeholders, usually via the monthly Care Group meetings.
Carry out
ad hoc assurance, risk management and compliance-related projects on behalf of
the Head, and the Senior Associate Director, of Assurance and Compliance
(typically requested by the Audit Committee or Chief Executive).
Implement
policies and propose changes to practices and procedures for the area of
Assurance and Compliance which impact across the Trust.
Participate
in in-house training as required
Co-ordinate
the management and review of Patient Safety leaflets throughout the Trust.
Job description
Job responsibilities
The candidate will:
Take the
lead role in reviewing risk registers routinely and particularly ahead of
Executive risk review meetings providing reports to the Senior Associate
Director of Assurance and Compliance on issues arising and working with risk
owners to resolve issues.
Take the
lead role in undertaking audits of the accuracy of risk registers in each area.
Initially audits will be undertaken at least bi-monthly, and monthly for those
areas requiring intensive support.
Provide
expert advice and training in risk management to senior managers across the
Trust, and maintain and update training documentation and guidance on the risk
management process and the risk management system.
Provide
content on behalf of the Senior Associate Director of Assurance and
Compliance for complete the Quarterly Assurance and Risk report to the Board,
with particular reference to the interpretation and analysis of significant
risks and trends and themes in risk registers.
Completing
monthly reports to the Trusts Integrated Quality and Assurance Committee on a
range of quality indicators and trends, interpreting the information
competently to highlight both assurance and areas for improvement.
Take the
lead role in ensuring that NICE Guidance is being reviewed and implemented
accordingly throughout the Trust. Reviewing the NICE database routinely and
particularly ahead of Care Group Governance meetings at which monthly reports
are provided for information and discussion.
Provide
content to the Head of Assurance and Compliance for quarterly assurance care
group quality and performance review meetings, underlining any anticipated
problems or concerns and highlighting issues for escalation.
Provide
expert support and advice to clinicians and service managers across the Trust,
providing guidance on the NICE process and where issues are identified work
with clinicians to resolve those issues.
For those areas requiring more intensive support, undertake meetings to
provide more concentrated guidance.
Provide
monthly reports of overdue internal audit recommendations to the Senior
Associate Director of Assurance and Compliance and follow up any issues,
agreeing and following through actions with relevant stakeholders.
Complete
quarterly monitoring reports to the Audit Committee on the status of overdue
internal audit recommendations and rates of implementation.
Maintain
the External Visit database, follow up any issues, agreeing and following
through actions with relevant stakeholders and challenge compliance where
necessary. Produce reports according to reporting schedules.
Support
the Head of Assurance and Compliance in communicating and co-ordinating complex
activities to meet standards and expectations set by the Care Quality
Commission (CQC) and to assist the Trust in maintaining its registration, by
completing allocated tasks and discrete projects.
Take an
active role in implementing Trust quality assurance processes focused on
assessing CQC regulatory compliance, at ward, service and Trust level, interpreting
and reporting outcomes to enable care group and service leaders to take
appropriate action and helping to continuously improve these processes.
Undertake
a critical friend role working alongside Care Groups and Corporate
Directorates to develop their assurance, risk management and governance
processes. This will involve constructively challenging existing processes and
facilitating improvement and will require attendance at Care Group meetings. It
will also entail the provision of subject matter expertise.
Plan
training and audit programmes and complex sub-programmes of work to gather
assurance on behalf of the Board and to implement and embed compliance with
regulatory requirements.
Prepare
Care Group exception reports and, for a portfolio of care groups, where
necessary, lead the communication regarding outstanding issues with the
relevant stakeholders, usually via the monthly Care Group meetings.
Carry out
ad hoc assurance, risk management and compliance-related projects on behalf of
the Head, and the Senior Associate Director, of Assurance and Compliance
(typically requested by the Audit Committee or Chief Executive).
Implement
policies and propose changes to practices and procedures for the area of
Assurance and Compliance which impact across the Trust.
Participate
in in-house training as required
Co-ordinate
the management and review of Patient Safety leaflets throughout the Trust.
Person Specification
Special Requirements
Essential
- Flexibility to work between the hours of 8am 7pm (with reasonable notice) to cover stakeholder meetings.
- Present a professional image at all times.
- Ability to travel across Trust sites as required.
Special Skills & Knowledge
Essential
- A sound and detailed understanding of the CQCs regulatory framework and the ability to apply it in practice.
- Complete and current understanding of the principles and practice of risk management and how to apply them in practice in an NHS environment.
- A sound, practical understanding of the principles and practice of planning and delivering assurance.
- Complete and current understanding of the principles of NHS quality governance.
- A high level of data literacy, including the ability to analyse, interpret and present complex information, and to triangulate different and knowledge sets for the purposes of assurance and identifying areas for quality improvement.
-
- Good knowledge of Microsoft packages, especially Word and Powerpoint but also Excel and Access.
- Diplomatic and confident in manner with effective of influencing and negotiating skills.
- Effective coaching and facilitation skills.
- Ability to act on own initiative with evidence of autonomous decision making.
- Self-motivated.
-
- Self-confident with the ability to work under and respond to pressure.
- Ability to work independently and without direct supervision.
- Strong communication skills with the ability to produce clear, accurate written and verbal reports, including the presentation of complex content relating to risks, assurance, compliance and governance.
-
- Effective listening skills.
- Effective presentational skills.
- Effective time management and organisational skills with the ability to work to strict deadlines.
Desirable
- Knowledge, and evidence of practical application of it, with respect to development of one or more of assurance, governance and compliance systems in an NHS environment.
- Evidence of the development and use of external networks to support sharing of good practice in risk management, assurance or governance.
Qualifications
Essential
- Educated to degree level, or equivalently qualified through experience.
- Evidence of continued professional and educational development, preferably with evidence of training and qualifications relevant to risk management and one or more of governance / or compliance in a public sector environment to post-graduate diploma level or similar.
Desirable
- Evidence of relevant training and qualifications in and NHS environment.
- PRINCE2 Foundation or Practitioner
- A formal auditing qualification (ISO9001 / internal audit etc).
Experience
Essential
- Concentrated, practical experience in implementing risk management and one or more of compliance, governance or assurance processes on a sustained basis in the NHS.
- Able to evidence a track record of coaching and facilitating improvement in risk management (and one of governance, assurance or compliance) working with a range of stakeholders.
- Practical experience of undertaking audits, or operating monitoring processes to determine compliance with standards and laid down processes.
- Experience of applying CQCs regulatory framework in practice including interpreting CQCs key lines of enquiry / quality statements and the gathering of evidence against them.
Desirable
- Experience of providing risk and control advice to major projects.
- Experience of providing formal training in risk management.
Person Specification
Special Requirements
Essential
- Flexibility to work between the hours of 8am 7pm (with reasonable notice) to cover stakeholder meetings.
- Present a professional image at all times.
- Ability to travel across Trust sites as required.
Special Skills & Knowledge
Essential
- A sound and detailed understanding of the CQCs regulatory framework and the ability to apply it in practice.
- Complete and current understanding of the principles and practice of risk management and how to apply them in practice in an NHS environment.
- A sound, practical understanding of the principles and practice of planning and delivering assurance.
- Complete and current understanding of the principles of NHS quality governance.
- A high level of data literacy, including the ability to analyse, interpret and present complex information, and to triangulate different and knowledge sets for the purposes of assurance and identifying areas for quality improvement.
-
- Good knowledge of Microsoft packages, especially Word and Powerpoint but also Excel and Access.
- Diplomatic and confident in manner with effective of influencing and negotiating skills.
- Effective coaching and facilitation skills.
- Ability to act on own initiative with evidence of autonomous decision making.
- Self-motivated.
-
- Self-confident with the ability to work under and respond to pressure.
- Ability to work independently and without direct supervision.
- Strong communication skills with the ability to produce clear, accurate written and verbal reports, including the presentation of complex content relating to risks, assurance, compliance and governance.
-
- Effective listening skills.
- Effective presentational skills.
- Effective time management and organisational skills with the ability to work to strict deadlines.
Desirable
- Knowledge, and evidence of practical application of it, with respect to development of one or more of assurance, governance and compliance systems in an NHS environment.
- Evidence of the development and use of external networks to support sharing of good practice in risk management, assurance or governance.
Qualifications
Essential
- Educated to degree level, or equivalently qualified through experience.
- Evidence of continued professional and educational development, preferably with evidence of training and qualifications relevant to risk management and one or more of governance / or compliance in a public sector environment to post-graduate diploma level or similar.
Desirable
- Evidence of relevant training and qualifications in and NHS environment.
- PRINCE2 Foundation or Practitioner
- A formal auditing qualification (ISO9001 / internal audit etc).
Experience
Essential
- Concentrated, practical experience in implementing risk management and one or more of compliance, governance or assurance processes on a sustained basis in the NHS.
- Able to evidence a track record of coaching and facilitating improvement in risk management (and one of governance, assurance or compliance) working with a range of stakeholders.
- Practical experience of undertaking audits, or operating monitoring processes to determine compliance with standards and laid down processes.
- Experience of applying CQCs regulatory framework in practice including interpreting CQCs key lines of enquiry / quality statements and the gathering of evidence against them.
Desirable
- Experience of providing risk and control advice to major projects.
- Experience of providing formal training in risk management.
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
County Durham & Darlington NHS Foundation Trust
Address
Darlington Memorial Hospital NHS Trust
Hollyhurst Road
Darlington
County Durham
DL3 6HX
Employer's website
https://www.cddft.nhs.uk/ (Opens in a new tab)