Assurance & Compliance Lead

County Durham & Darlington NHS Foundation Trust

This job is now closed

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

Date posted

01 November 2024

Pay scheme

Agenda for change

Band

Band 6

Salary

£37,338 to £44,962 a year

Contract

Permanent

Working pattern

Full-time

Reference number

C9439-24-1118

Job locations

Darlington Memorial Hospital NHS Trust

Hollyhurst Road

Darlington

County Durham

DL3 6HX

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:

Complete quarterly monitoring reports to the Audit Committee on the status of overdue internal audit recommendations and rates of implementation.

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.

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.