About this role
Job summary
Supports the Group retain oversight of external agency visits, including those from regulators, and works to ensure the organisation can provide evidence to demonstrate compliance.Supports the of Compliance Manager to provide the Group with a clear view of its compliance with expected standards of care and support proactive work to identify risks and bridge any gaps associated with non-compliance. The post holder will specifically work with the Compliance Manager in delivering unconditional registration with the Care Quality Commission.Support a programme of work designed to test compliance through visits and testing of assurance data.Provide line management oversight to the Compliance Administrator and oversees the wider directorate administrative resource to ensure a seamless support function.
Main duties of the job
Contributing to Care Quality Commission (CQC) readiness across the Group
Working with the Compliance Manager, ensure that external agency visits (including CQC) that require support from the central Compliance team have a comprehensive plan in place and take an active lead role in seeking out necessary evidence from within the organisation of compliance.
Support in the effective communication of key messages, that are sometimes contentious, to result in a positive and constructive outcome
Support with all elements of inspection activities including in preparation and planning, support with logistical arrangements for the visit including support to collating requests for evidence, obtaining the evidence
Identifying key compliance related risks facing the Group and ensure these are recorded and, supporting the Compliance Manager, identify mitigations.
About us
Lincoln Hospital is a thriving university city and with the opening of the medical school, it provides all major specialties and a 24-hour major accident and emergency service.
United Lincolnshire Hospitals NHS Trust has been granted teaching hospital status, after demonstrating evidence to significant teaching commitment. From now on it will be known as United Lincolnshire Teaching Hospitals NHS Trust.
Pilgrim Hospital is situated in beautiful countryside and serves the communities in the South Lincolnshire area. It provides all major specialties and a 24-hour major accident and emergency service.
Grantham and District Hospital serves the communities of Grantham and the local area. It provides ambulatory paediatric and accident and emergency services.
Lincolnshire Community Health Services NHS Trust (LCHS) and United Lincolnshire Hospitals NHS Trust (ULHT) have come together in a Group arrangement, with the goal of improving the care provided to patients across the county.
This will not constitute a formal merger of the two organisations, but will bring the Trusts together under a single Board and Executive Leadership Team, with the goal of improving the care that is provided to patients both in the community and in hospitals across Lincolnshire. Both Trusts will retain their separate statutory names and legal obligations.
The Group will be known as Lincolnshire Community and Hospitals NHS Group (LCHG).
Job description Job responsibilities
Develop and implement quality assurance systems derived from monitoring processes of Group activity and performance against local and national guidelines and policies of the Group, by means of local inspections, visits, scrutiny of assurance data where information already exists or the development of surveys and audits to obtain data for this purpose. Participate in these programmes designed to test compliance. Assist in the scrutiny of compliance at divisional level.Contributing to Care Quality Commission (CQC) readiness across the Group by supporting the Compliance Manager analyse, triangulate and report on outcomes from quality assurance systems and identify evidence of compliance and seek assurance that this is becoming embedded into routine practice.Working with the Compliance Manager, ensure that external agency visits (including CQC) that require support from the central Compliance team have a comprehensive plan in place and take an active lead role in seeking out necessary evidence from within the organisation of compliance, building strong networks with a wide range of stakeholders, and submitting this in line with tight deadlines, and in line with appropriate data security principles. Maintain comprehensive records to register evidence provided.Ensure systems are in place to assess the quality of data and evidence, checking for accuracy of data entered and ensuring completeness prior to submission.Working diligently and with close attention to detail support the process to check external agency visit reports (including CQC) for factual accuracy and lead on the process to collate this to enable the Group to respond within timescales.Assist in the accurate sourcing and collation of both qualitative and quantitative data and information, triangulating multiple data sources and work streams to produce clear reporting that provides assurance to the Group and external agencies (including CQC).Support in the effective communication of key messages, that are sometimes contentious, to result in a positive and constructive outcome (i.e. whistleblower concerns, CQC concerns and CQC inspection outcomes).Support with all elements of inspection activities including in preparation and planning, support with logistical arrangements for the visit including support to collating requests for evidence, obtaining the evidence, sense checking this along with effective organisation skills to ensure interviews and focus groups are arranged and prepared for.Provide expert guidance and support to the Group in the development of local services aspiring to good and outstanding characteristic ratings within CQC domains of care and CQC self-assessment toolkits (Key Lines of Enquiry (KLOE) and quality statements).Assist in the review of documents utilised as compliance evidence and seek to ensure these are regularly reviewed and assessed to improve and meet regulatory standards.Develop strong and effective working relationships with key stakeholders, including within Divisions and develop and maintain systems to ensure action plans are agreed, implemented and monitored by the relevant services/clinical teams and support with preparation of regular reports on the progress of projects. Support sharing areas of good practice and support with constructive challenge of proposed actions.Advising the Compliance Manager on progress and any potential gaps or issues that may put compliance at risk.Identifying key compliance related risks facing the Group and ensure these are recorded and, supporting the Compliance Manager, identify mitigations.Oversee, populate, update and report from the external agency visits register on an ongoing basis to ensure that external agency visits, including those from high-profile celebrities and VIPs are visible and any risks highlighted.To be responsible for providing line management for the Compliance Administrator, effectively delivering a managerial function to include appraisal and development plans, annual leave management, conduct and performance and grievance management. Ensure the Compliance Administrator delivers on their respective objectives and priorities in support of the Teams objectives and priorities.Provide oversight arrangements and guidance to the Directorates administrative resource to ensure that they support Directorate teams through proactive forward planning, scheduling of internal papers being required, issuing of timely reminders and cross cover arrangements to support with administration of meeting duties (i.e. taking minutes, action notes and support with agenda calls for papers as necessary.Managing and implementing multiple projects at any one time and prioritising own time and workload effectively and flexibly to meet deadlines and other needs arising.Maintaining and developing own knowledge by attending further training, briefings, conferences as required, and mandatory training.Maintaining an awareness of local and national developments that will have impact across the Group.Advising, supporting and training colleagues within the team and across the Group, in large and small groups and individually, on relevant areas as required.Develop effective working relationships with the Groups Communications Team and support with the sharing and communication of key proactive and reactive messages to prepare and equip the staff.Contributing to the development of a culture of continuous improvement, challenging orthodoxy and the established way of doing things, promoting evidence based approach, where positive change is more welcomed than resisted.
Person Specification
Qualifications Essential
Educated to Post-graduate diploma level, equivalent experience or equivalent qualification. Evidence of ongoing personal development
Desirable
Healthcare and/or relevant professional qualification. IT qualification or equivalent
Skills/competencies Essential
Ability to analyse data and make judgements. Strong administrative and organisational skills including accurate records management. Skilled in the use of Microsoft Windows based applications including Word, Excel and PowerPoint. Good verbal and written communication skills.
Knowledge Essential
Knowledge and or experience creating/designing and implementing Data systems. Knowledge and or Experience of completing data audits. Be familiar with Data Protection Act and Freedom of Information (FOI) act.
Desirable
Knowledge of medical & legal terminology Knowledge of information governance regulations and requirements as they relate to healthcare service providers. An understanding of the regulatory framework applicable to the delivery of healthcare services in an acute and community setting.
Experience Essential
Extensive experience of working with business management IT systems and databases. Experience of providing staff line management.
Desirable
Experience working in a healthcare setting
Special attributes/specific requirements Essential
The ability to extract and analyse complex data from business management IT systems and databases. Self-motivated and committed to improving the quality and safety of healthcare services within the Group.
Personal qualities Essential
Understanding of and commitment to the Group's values
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.
Certificate of Sponsorship Applications from job seekers who require current Skilled worker sponsorship to work in the UK are welcome and will be considered alongside all other applications. For further information visit the UK Visas and Immigration website (Opens in a new tab).
From 6 April 2017, skilled worker applicants, applying for entry clearance into the UK, have had to present a criminal record certificate from each country they have resided continuously or cumulatively for 12 months or more in the past 10 years. Adult dependants (over 18 years old) are also subject to this requirement. Guidance can be found here Criminal records checks for overseas applicants (Opens in a new tab).
Employer details Employer name United Lincolnshire Hospitals NHS Trust
Address Lincoln County Hospital
Greetwell Road
Lincoln
LN2 5QY
United Kingdom
Employer's website https://www.ulh.nhs.uk/ (Opens in a new tab)