OUR VISION IS TO PROVIDE THE SAFEST AND KINDEST CARE IN THE NHS HEAD OF ASSURANCE CANDIDATE INFORMATION PACK MAY jobs.sath.nhs.

Transcription

1 OUR VISION IS TO PROVIDE THE SAFEST AND KINDEST CARE IN THE NHS HEAD OF ASSURANCE CANDIDATE INFORMATION PACK MAY 2018 jobs.sath.nhs.uk 1

2 DEAR CANDIDATE, Thank you for your interest in this role, which is a key role in delivering the Trust s assurance agenda. This is an exciting opportunity for an individual keen to provide strong leadership in assuring the delivery of the Trust s strategic objectives. You will work closely with our Senior Leadership Team and the executive and Non-Executive Directors to improve clinical quality and patient safety to continue the Trust s journey towards becoming safest and kindest and our patients tell us they received kind care. We are embarking upon an exciting programme of change as it delivers its reconfiguration programme and continues its journey of transformation in partnership with the Virginia Mason Institute. These changes must be managed against a background of sustained performance against our key checkpoints, inspections and assurance requirements. The Head of Assurance will be key in ensuring that we are able to provide assurance that robust processes are in place to support both service change and business as usual activities. I look forward to hearing how you can help us on this journey Yours faithfully, JULIA CLARKE CORPORATE MANAGEMENT DIRECTOR jobs.sath.nhs.uk

3 CONTENTS 4 ABOUT THE TRUST, OUR SERVICES, COMMUNITIES AND PARTNERSHIPS 9 EDUCATION AND TEACHING 10 OUR STRATEGY AND VALUES 11 HOW WE ARE DELIVERING CHANGE 12 LIVING AND WORKING IN SHROPSHIRE 17 PERSONAL SPECIFICATION 19 JOB DESCRIPTION 3 jobs.sath.nhs.uk

4 ABOUT THE TRUST The Shrewsbury and Telford Hospital NHS Trust is the main provider of acute hospital services for around half a million people in Shropshire, Telford & Wrekin and mid Wales. Encompassing some of the most picturesque parts of England and Wales, the Trust s catchment stretches from the Cambrian Mountains in the west to Newport and the fringes of the Black Country in the east. The main towns include: Bridgnorth, Ludlow, Market Drayton, Oswestry, Shrewsbury and Whitchurch (in Shropshire); Newport, Telford and Wellington (in Telford & Wrekin); and Newtown and Welshpool (in Powys) all beautiful and unique. Our main service locations are the Princess Royal Hospital (PRH) in Telford and the Royal Shrewsbury Hospital (RSH) in Shrewsbury which are located 20 minutes drive apart, which together provide 99% of our activity. Both hospitals provide a wide range of acute hospital services including accident & emergency, outpatients, diagnostics, inpatient medical care and critical care. We employ almost 6,000 staff, and hundreds of staff and students from other organisations also work in our hospitals. We benefit from around 1,000 wonderful volunteers at the Trust and our main charitable partners are the league of friends at the Royal Shrewsbury Hospital and at the Princess Royal Hospital and the Lingen Davies cancer appeal which is based at the Royal Shrewsbury Hospital. In addition to this we also provide services such as consultant -led outreach clinics at clinics at the Wrekin Community Clinic, Telford, the Robert Jones and Agnes Hunt Orthopaedic Hospital, Gobowen and the Bridgnorth, Ludlow and Whitchurch Community hospitals. We also provide midwife-led units at Ludlow, Bridgnorth and Robert Jones and Agnes Hunt Orthopaedic and District Hospital (RJAH). OUR VALUES Our Values During 2013 we worked with our staff and patients to develop a new framework of Values to drive our organisation. Our Values were shaped by our staff and patients, to ensure we got them right. Our Values are not just words on a page, they represent what we are about here at SaTH. They represent the behaviours and attitudes we expect each of our staff to display when they re at work and representing our organisation. Since they were launched, we have continued to embed them throughout the Trust, including using Values, behaviours and attitude interviewing in our recruitment process. The Values are the foundation to our Organisational Strategy. 4 jobs.sath.nhs.uk

5 PRINCESS ROYAL HOSPITAL TELFORD (PRH) PRH opened in It generally serves Telford & Wrekin and eastern Shropshire as well as being the Trust s main centre for inpatient head and neck services (and currently hyper-acute and acute stroke services on a temporary basis). PRH has approximately 285 acute adult inpatient beds and 36 acute paediatric inpatient beds, with three beds allocated for haematology and oncology and an eight bedded Children s Assessment Unit. It also has 24 surgical day case beds and a 20- station renal dialysis unit. The hospital also includes a private outpatient facility (the Apley Clinic). The hospital currently provides A&E, inpatient, outpatient and day case facilities. Services include general and acute medicine, inpatient head & neck, cardiology, breast surgery, urology, critical care, trauma & orthopaedic services, paediatric services, emergency treatment and renal dialysis. PRH also provides day case treatment for general surgery including paediatrics, ophthalmology, haematology and oncology. In September 2014, PRH became our main centre for inpatient women and children s service when the 28 million Shropshire Women and Children s Centre opened. The Centre includes Consultant-Led Maternity Services, with a standalone Midwifery Led Unit on site, and is supported by a Level 2 Neonatal Unit. 5 jobs.sath.nhs.uk

6 ROYAL SHREWSBURY HOSPITAL SHREWSBURY (RSH) RSH opened in 1977 (although some services such as the Midwife Led Unit have been provided on the hospital since the 1960s). It generally serves Shrewsbury, western Shropshire and mid Wales as well as being the Trust s main centre for cancer services and acute surgery. RSH has approximately 370 acute adult inpatient in addition to 30 surgical day case beds, a 16 station chemotherapy day centre, and 24 renal dialysis stations. RSH provides A&E, inpatient, outpatient and day case services. Specialties include general and acute medicine, cardiology, general surgery, colorectal and upper GI surgery, vascular surgery, urology, gynaecology, critical care, trauma & orthopaedic services, medical day case for Paediatrics from Monday to Friday, emergency treatment, oncology & haematology, renal and ophthalmology. The Shropshire and mid Wales fertility Centre is currently located at The Royal Shrewsbury Hospital but will be relocating in the summer of 2018 to new premises on Sundorne Road, Shrewsbury. The 5 million Lingen Davies Centre provides improved facilities for oncology and haematology patients. The new surgical assessment and surgical short stay unit is part of the Royal Shrewsbury Hospital as our main centre for inpatient acute surgery. Since the opening of the Shropshire Women and Children s Centre at PRH in Telford, RSH has continued to provide midwife-led maternity services and outpatient services. 6 jobs.sath.nhs.uk

7 OUR COMMUNITIES AND PARTNERSHIPS THE MAJORITY OF OUR PATIENTS AND COMMUNITIES LIVE IN THREE LOCAL AUTHORITY AREAS: Shropshire Council (unitary county authority, Conservative-led administration) Telford & Wrekin Council (unitary borough authority, Labour-led administration) Powys County Council (unitary county authority, Independent-led administration) - our catchment area predominantly covers the former county of Montgomeryshire which comprises the northern part of Powys. LOCAL NHS COMMISSIONING ORGANISATIONS HAVE THE SAME BOUNDARIES AS OUR LOCAL AUTHORITIES AND ARE: Shropshire Clinical Commissioning Group Telford & Wrekin Clinical Commissioning Group Powys Teaching Health Board Specialised commissioning is undertaken through NHS England (Shropshire and Staffordshire Area Team) and Welsh Health Specialised Services Commissioning. 7 jobs.sath.nhs.uk

8 WE WORK IN PARTNERSHIP WITH A WIDE RANGE OF ORGANISATIONS FOR THE DELIVERY AND PLANNING OF HEALTH SERVICES. THE MAIN STATUTORY BODIES INCLUDE: Local Authorities (see previous page) NHS Commissioning Bodies (see previous page) Primary care services Other providers of health and care services for Shropshire, Telford & Wrekin and mid Wales: - Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust (specialist orthopaedic) - Shropshire Community Health NHS Trust (community services) - South Staffordshire and Shropshire Healthcare NHS Foundation Trust (specialist mental health and learning disabilities) - West Midlands Ambulance Service NHS Foundation Trust (ambulance and patient transport) - Welsh Ambulance Services NHS Trust (ambulance and patient transport) The main statutory bodies to represent the public interest in health services include: - Health Overview and Scrutiny Committee Fees for Shropshire Council and Telford & Wrekin Council - Local Healthwatch bodies for Shropshire and Telford & Wrekin - Powys Community Health Council 8 jobs.sath.nhs.uk

9 EDUCATION AND TEACHING THERE ARE THRIVING POSTGRADUATE CENTRES AT BOTH HOSPITALS. We are an undergraduate teaching hospital through our partnership with Keele University. Last year Keele University s Medical School finished second in the league tables for student satisfaction, with only Oxford s medical school rated higher, and fourth in the Guardian newspaper s university league table for medicine, with only Oxford, Cambridge and University College London finishing higher. The majority of consultants are involved with medical education and a substantial number have sessions seconded to the medical school and hold substantive or honorary university titles. There is a Dean and Deputy based at the Trust who oversee the delivery of the undergraduate curriculum and manage the academic staff. Academic staff perform many of the central roles of the Medical School including participation in admissions, examinations, GMC inspections, formal review of health, conduct, and progress of students and membership of senior committees. There is a programme of faculty meetings and opportunities for formal teaching training both at the Trust and at the main university campus. We are a very high recruiter to national trials and for many trials we are the highest recruiter in the region. Given the academic pedigree of consultants appointed here, research continues to be an interest within departments and we are look forward to developing further academic links to enhance our research pedigree. We also benefit from our education partnership with Staffordshire University, with on-site facilities to support the training of our nursing, midwifery and allied health professional workforce. The Guardian s University Guide (2013) ranked the University s courses as 1st in England for nursing and paramedical programmes. THE UNDERGRADUATE TRAINING PROGRAMME Led by Dr Koottalai Srinivasan, Director of Undergraduate Medical Education (consultant in respiratory medicine). Medical Education is led by Dr John Jones. THE POSTGRADUATE TRAINING PROGRAMME Led by Dr Jenni Rowlands, (consultant radiologist). 9 jobs.sath.nhs.uk

10 OUR STRATEGY We launched our Organisational Strategy with the vision of providing the safest and kindest care in the NHS. We developed our Strategy through a series of staff engagement events to ensure it is a collective view of where we want to be as an organisation. Our collective objective is delivering this strategy. PATIENT AND FAMILY VISION The Safest, Kindest care in the NHS MISSION Healthiest Half Million Population on Planet Earth LEADERSHIP Innovative and inspirational leadership that delivers our vision OUR PEOPLE Values in Practice PROUD TO CARE MAKE IT HAPPEN WE VALUE RESPECT TOGETHER WE ACHIEVE 10 jobs.sath.nhs.uk

11 HOW WE ARE DELIVERING CHANGE The Trust is proud to have been working collaboratively with the Virginia Mason Institute in Seattle, widely regarded as one of the safest Hospitals in the World. We have progressed with a number of Value Streams. Our Doctors, Nurses, Allied Health Professionals and colleagues are working together with Virginia Mason to transform healthcare at The Shrewsbury and Telford Hospital NHS Trust and share our learning across the Country. Our current Value Streams are Respiratory Discharge, Sepsis, Workforce and Recruitment and Outpatients. Sponsor teams have ownership of the programme and run Rapid Process Improvement weeks that allow our workforce to try new processes and procedures that may improve the care we offer to our patients. Any proposals made are tested, measured and fully supported to ensure that they become embedded into our normal daily work and remain sustainable in the long term. This process aligns to our Organisational Strategy putting our Patients First and reflects the Values of our Trust. There will be many opportunities for you to become involved in our KPO and value Stream work and we will be able to provide you with help and guidance independent of your level of expertise. We have a unique opportunity to make a difference and we hope that you will want to be a part of our journey. Our Kaizen Promotion Office (KPO) provides the support for this work. Every Value Stream has full Executive support and the entire Executive team have an important role to play on the Guiding team and our overall Transformation programme. We are very proud of our achievements to date and are looking for ways to engage with all of our staff through our Transformation work and our Leadership Academy launched in November OUR LEADERSHIP ACADEMY Our Leadership Academy is pivotal to developing a culture which provides the safest and kindest care possible and to supporting and developing leaders at all levels across our organisation by providing the right tools to do the job. 11 jobs.sath.nhs.uk

12 LIVING AND WORKING IN SHROPSHIRE Shropshire is a wonderful place to live,and few people would disagree. Shrewsbury has been named as one of the best places to live in the country in the Sunday Times Best Places to Live Guide. The majority of our staff live within our main local catchment area of Shropshire, Telford & Wrekin and mid Wales. Between them these three areas offer a rich variety of places to live. NIGHTLIFE AND CULTURE Shrewsbury, Telford and the surrounding areas offer a whole host of activities to keep you occupied outside of working life. Whether you prefer watching a blockbuster in a building dating back to 1596 or dancing till the early hours, there is something for everyone. Shrewsbury is rich in history and culture, all displayed in the towns quaint architecture. The town boasts an impressive selection of independent restaurants, bars, theatre, live music venues and nightclubs all set among the pretty cobbled streets. This vibrant town has seen a massive boom in nightlife recently with the addition of Shrewsbury University with regular events organised to satisfy all tastes. However, the heart of Shrewsbury is the Quarry, in the weave of the River Severn. The Quarry is home to the famous Shrewsbury Flower Show, the Splash Park (opened 2016) attracts youngsters of all ages, and then there are the variety of events that take place throughout the year from The Winter Festival or the Dragon Boat Festival. You can even rent a rowing boat and sail down the river yourself, or watch the many rowers from the Boat House Pub overlooking the River. Telford is the birthplace of the Industrial Revolution with many places of historic interest including the Ironbridge Gorge Museum. Telford is also close proximity to Weston Park, the home of a wide range of events are hosted at this stately home and country park, including international horse trials. Just a short journey away is Ludlow. A town renowned for the high-quality music and theatre performances stages at the annual Ludlow Shakespeare and Arts Festival, whilst the town also hosts an excellent annual Food Festival building on the town s reputation as a great destination for restaurants and local produce. 12 jobs.sath.nhs.uk

13 SHOPPING Shrewsbury and Telford offer a diverse range of shops, they are also complemented by a wealth of nearby market towns, and villages. Telford Shopping Centre is located in the heart of Telford, with over 160 of your favourite high street stores and easy parking. The shopping centre is just across from Southwater, the exciting new leisure quarter which has an array of shops, restaurants, cafes, IMAX cinema, hotel, ice rink and modern library. Shrewsbury has two main shopping centres The Darwin Centre and Pride Hill Centre. These shopping malls sit among the old streets of Shrewsbury which host a unique ray of independent shops, cafes and restaurants. Local villages that surround Shrewsbury and Telford are not to be overlooked. For example, Bishop s Castle offers an unexpected variety of art, antiques, crafts and textile shops alongside the renowned Three Tuns local brewery. OUTDOOR PURSUIT One of the main attractions of this area is the fantastic outdoor life, both within Shropshire, Telford & Wrekin and mid Wales and in nearby Snowdonia and the Brecon Beacons. The area is rich with opportunities for walking, cycling, horse riding, camping, mountaineering, canoeing and sailing, gliding and other outdoor pursuits. Ready access to the Wrekin, the Shropshire Hills including the Long Mynd, Upland Powys, the Severn & Wye valleys, Shropshire Canals and meres, and the Welsh coast add to the wide range of activities available. Wildlife highlights include the conservation of Red Kites and Ospreys in western Montgomeryshire, and the county boasts one of the most varied geologies in the British Isles from Precambrian sedimentary rocks of Haughmond Hill to the igneous intrusions in the South Shropshire Hills. For the really adventurous amongst you there are few counties with access to such a wealth of outdoor pursuits. From paragliding in Long Mynd, Tandem and Solo Parachuting in Whitchurch, you can learn to fly just outside of Shrewsbury at the Shropshire Aero Club, and with easy access to North Wales there is no end of outdoor activities on the land, in the water, or even below the ground. PEOPLE WHO VISIT COME WITH NO EXPECTATIONS BUT THEY ALWAYS LEAVE WITH A SENSE OF WANTING TO COME BACK. PEOPLE COME AS A DAY VISITOR AND END UP ULTIMATELY MOVING HERE. HELEN BALL SHREWSBURY TOWN CLERK 13 jobs.sath.nhs.uk

14 HOUSING Shropshire is regularly named as one of the diverse but safest places to live in the UK. The local area offers a wide range of housing to suit every need, from town centre flats to remote farmhouses and converted barns. Whether you are looking to buy or rent Shropshire has housing to suit all. Both main hospitals are located by large residential areas, so there is an abundance of accommodation close to work. Or, if you are looking for something quieter, then there are rural towns such as Ironbridge, Newport and Much Wenlock, or our picturesque villages located in Pontesbury, Allscot, Weston Lullingfields - all within easy commutable distance of the hospitals. The county also has many affordable housing offers for first-time buyers, or those with investment interests have both the available housing and buoyant rental market to capitalise on. UNIVERSITIES The up and coming University Centre Shrewsbury offers high quality teaching, learning and research in a distinctive medieval town with a vibrant and stylish town centre. But there are also a number of universities within easy commuting distance from Shropshire such as the University of Birmingham, University of Chester, University of Liverpool, University of Wolverhampton (Telford s local University), Harper Adams University, Keele University, and Staffordshire University. SCHOOLS If you are a family living in, or moving to Shropshire, you will be satisfied by the many excellent schools and their results in national assessments. Shropshire has a strong commitment to providing opportunities for every child and young person to achieve their potential. There are 61 primary schools, 20 secondary schools and 46 independent private schools within the county. Shropshire schools continually rank above average in the league tables with schools such as Newport Girls High School and Shrewsbury School often achieving a 100% GCSE A-C pass rate. For younger children, there are various childcare options available both on-site and off for staff at RSH and PRH. Daisy Chain day care is located at the Royal Shrewsbury Hospital, which gives priority to NHS staff. The nursery has superb facilities for children including a small forest school and a sensory room. Honeybuns is situated on the Princess Royal Hospital grounds and offers a really flexible solution to all your childcare needs, with discounts available for all NHS employees. There are also many excellent private nurseries if you find they are more suited to your needs. 14 jobs.sath.nhs.uk

15 TRANSPORT Shropshire has an excellent central location making it accessible to both the north and the south of the country, as well as being approximately 60 minutes from the nearest beach and airport. PUBLIC TRANSPORT Shropshire is well connected within the county with regular local buses and 19 National Rail services. London Midland, Arriva Train Wales and Virgin Trains are the three key rail operators with frequent links to Birmingham, Manchester and Wales. A direct service runs from Shrewsbury to London, meaning the capital can be reached in just over 2 hours. To the west, there is easy access to Snowdonia, the Brecon Beacons and the Cambrian Coast. ROADS Shrewsbury and Telford are both easily accessible from the national motorway network via the A5 dual carriageway and M54 motorway. The north of the county has good road transport links to Merseyside and Greater Manchester. Birmingham can be reached in under an hour and London is approximately 3 hours away. Liverpool Shrewsbury Telford Manchester Birmingham Derby East Midlands AIRPORTS Shropshire is lucky to be in close Stratford-upon-Avon proximity to three international airports - Manchester, Liverpool Stanstead and Birmingham airport (approx Oxford one hour drive) and within easy reach of the main London Airports. Cardiff Bristol Heathrow London Gatwick 15 jobs.sath.nhs.uk

16 PLACES OF WORSHIP Shropshire is a diverse county, with a range of places to worship to suit your own personal beliefs. During working hours personal practise can be conducted within the dedicated multi-faith spaces at both The Royal Shrewsbury Hospital and Princess Royal Hospital and all religions are welcomed. These private spaces are available to any person or group for private prayer or worship group. BELOW IS AN EXAMPLE LIST OF PLACES OF WORSHIP AVAILABLE IN THE LOCAL AREA OUTSIDE OF WORKING HOURS: The Cathedral Church of Our Lady Help of Christians and Saint Peter of Alcantara 11 Belmont, Shrewsbury SY1 1TE. Phone: Fr Canon Jonathan Mitchell St Patrick s Telford King Street, Wellington, Telford TF1 3AP. Fr Alban Greenwood Guru Nanak Gurdwara 1 Hadley Park Road, Hadley, Telford, Shropshire TF1 6PW, Phone: Telford Central Mosque King Street, Wellington, Telford TF1 1NZ, Phone: Shrewsbury Muslim Centre 2 Preston Street, Shrewsbury SY2 5NY, Phone: , info@shrewsburymuslimcentre.org Hindu Cultural Resource Centre Telford Bank Road, Dawley, Telford, Shropshire, TF4 2AZ, Phone: , info@hinducrct.org Satipanya Buddhist Trust Satipanya, White Grit, Minsterly, Shropshire, SY5 0JN, Phone: Shrewsbury Triratna Buddhist Centre Queen St, Shrewsbury, Shropshire, SY1 2JU Telford Buddhist Priory 49, The Rock, Telford, TF3 5BH Shropshire Humanist Group Meetings are held at University Centre Shrewsbury, Guildhall, Shrewsbury SY3 8HQ Solihull & District Hebrew Congregation 3 Monastery Dr, Solihull 16 jobs.sath.nhs.uk

17 PERSON SPECIFICATION POST: HEAD OF ASSURANCE JOB REQUIREMENT ESSENTIAL DESIRABLE General educational qualifications Degree. What are the general educational requirements for this post? Professional/technical qualifications What professional, technical qualifications are required for the post? A management qualification. Evidence of professional development at senior level. Work experience What work experience is required in what type of role and how long for? At least 5 years experience in clinical governance. A minimum of 3 years leading a team and working at a senior management level. Experience of working in an acute NHS Trust. Experience of project management. Experience of working with a wide range of people from different backgrounds. Experience in training medical nursing and other staff. Experience of handling data. Clinical /professional qualification. Links with primary care. Knowledge What knowledge is required for the post? Masters level knowledge of corporate and clinical governance. Expert knowledge of clinical audit and risk management. Expert knowledge of Freedom of Information. Knowledge of clinical coding and clinical information systems. Sound knowledge and understanding of national developments in governance. Knowledge of clinical effectiveness and evidence based practice. Sound knowledge of legal framework for risk management. 17 jobs.sath.nhs.uk

18 JOB REQUIREMENT Skills What skills are required for the post? (e.g. communication, interpersonal, planning and organisation, analysis, judgement, decision making, physical or mental skills) ESSENTIAL Highly developed negotiating and influencing skills. Excellent and influential communication skills both verbal and written, including presentation skills. Ability to establish and maintain influential working relationships at all levels, internally and externally. Strong leadership and management skills. Strong time management skills. Organisational and political awareness/astuteness. Excellent organisational and practical skills. Excellent IT and keyboard skills. The ability to analyse and report data. Able to interpret national policy and develop local policies. Other requirements not covered Are there any other job requirements not covered above? Evidence of personal and professional development. Flexible with a positive outlook. Problem solving skills. Completer/finisher. Self motivated high achiever. Car driver. Person Specification sign-off The agreed person specification must be signed by the manager MANAGER Name: Signature: Date: 18 jobs.sath.nhs.uk

19 JOB DESCRIPTION POST TITLE: HEAD OF ASSURANCE BASE: ROYAL SHREWSBURY HOSPITAL BUT REGULAR TRAVEL REQUIRED BETWEEN BOTH SITES DIVISION: CORPORATE GOVERNANCE RESPONSIBLE FOR: Health and Safety, (including moving and handling), Clinical Audit Department, EA to Trust Board, Communications Team, Assurance Team inc FOI, Engagement, Volunteers and sustainability. LIAISES WITH: Director of Corporate Governance Chief Executive and Trust Board members including Non-Executive Directors Care Group Management Teams Managers and Heads of Service Governance staff Legal Services Team Outside agencies POST PURPOSE/SUMMARY To play a full role in the corporate management and strategic direction of the Trust and be the nominated deputy to the Director of Corporate Governance with full delegated authority, representing the Director at Board level. To oversee the Trust s corporate governance agenda ensuring an integrated approach and contributing to the overall Governance agenda of the Trust. Develop the Board Assurance Framework in conjunction with the Trust Board. To manage and maintain the Corporate Risk Register, working with Centres to prepare submissions to the Operational Risk Group. Prepare regular updates to Audit Committee, Tier 2 Committees and Trust Board. Develop new and revised corporate strategies and policies in line with governance requirements and ensure that there is a system in place to develop all trust policies which is compliant with NHSLA standards. Be the system manager for Insight 4GRC including 4Risk risk register software; and 4Policy for dissemination of new and revised policies to managers. 19 jobs.sath.nhs.uk

20 POST PURPOSE/SUMMARY (CONTINUED) Provide reports to the Trust Board; Audit Committee and other Tier 2 Committees; Operational Risk Group: Health & Safety, Fire and Security Committee and other meetings as appropriate on matters relating to risk and assurance and other areas as appropriate e.g. clinical audit, national initiatives etc. Provide advice and support to the Communications Team particularly in relation to difficult issues. Overall responsibility for coordinating the work of the Clinical Audit Department ensuring links to the Assurance Framework. Provide leadership and direction to the teams. Monitor and report performance to the Trust Board, and other Committees in all these areas. Oversee Freedom of Information requests and the Trust responses. Oversee the Trust Conflicts of Interest Policy including providing advice to staff, and reviewing and adding interests to the Register of Interests and Gifts and Hospitality registers on Insight 4GRC as well as providing reports and liaising with LCFS on declarations made. ORGANISATION POSITION DIRECTOR OF CORPORATE GOVERNANCE HEAD OF ASSURANCE Health and Safety Team Manager 8a Clinical Audit Manager 8a PA Band 5 Sustainability Manager 8a Community Engagement Manager 8a Communications Team 2x band 7 + Band 6 Marketing and Charities Band 7 Health and Safety Team (5) 2x Band 6 + 2x band 5s + admin Clinical Audit Team FOI Band 4 Hamar Centre (5) Moving and Handling Team Band 7 + Band 5s + admin Travel and Transport Band 5 Community Engagement Facilitator Band 7 Volunteers admin Band 4 20 jobs.sath.nhs.uk

21 SCOPE & RANGE The jobholder will impact on all areas of the Trust, up to and including Board members. To be the overall lead for the assurance function as above To manage the budgets for clinical audit, assurance and health and safety To deputise for the Director of Corporate Governance as required working at associate director level. DECISIONS, JUDGEMENT & FREEDOM TO ACT The postholder will be expected to work autonomously referring to the Executive Director as appropriate. The postholder will be expected to organise their own work and direct the Governance staff. The postholder will be responsible for developing corporate policies and strategies across the Trust e.g., Risk Management Strategy and risk management policies. Interpret national guidance to ensure a framework of risk management policies are in place, which are NHSLA compliant. Review all new and revised risk management policies prior to submission to the relevant Committee for approval. Be responsible for the allocation of duties and responsibilities within the assurance team Oversee the responses to FOI requests and quality assure these ensuring that responses are timely and appropriate 21 jobs.sath.nhs.uk

22 MAIN DUTIES & RESPONSIBILITIES MANAGEMENT APPROACH Contribute to the development of the Trust governance arrangements to ensure it meets all its objectives, working closely with the Director of Corporate Governance. As a member of the senior management team, contribute to the strategic direction of the Trust through the promotion of integrated governance into the Trust s business planning and service development processes. Work with the Director of Corporate Governance developing the assurance framework for the Trust Board ensuring that it reflects national requirements and that risks, controls, gaps and assurances are identified and regularly updated. Work with Care Groups to develop local assurance frameworks and risk registers. Contribute to the development of the Trust s strategic direction, service planning and policies. Work with Board members to support the development of the Trust performance management framework and processes in relation to integrated governance. Contribute to the development of the annual Trust delivery plan by ensuring the integration of governance issues. Chair Operational Risk Group, Health and Safety, Fire and Security Committee, and Policy Approval Group and any other groups and committees as deemed appropriate. Continually review the effectiveness of the Trust s governance structures and make recommendations for improvement to the Trust Board to support an integrated governance agenda, comply with NHS requirements and with clear accountability and reporting lines. RISK MANAGEMENT Develop and maintain the Trust Risk Registers and provide regular reports to the Board, Audit Committee, and other meetings as appropriate. Oversee the running of the Operational Risk Group ensuring risks are reported, assessed and managed. Ensure that any unresolved issues or significant risks are identified and brought to the attention of the Trust Board for action and possible referral to other appropriate external bodies. Develop corporate risk management strategies and policies interpreting national guidance to fit the local context. Liaise with Internal Audit, External Audit and the LCFS in relation to Risk and Assurance. Be the system manager and develop the webbased Risk Registers (4Risk); providing training to Centres and Departments; monitoring use and providing reports to Trust Committees. Develop systems of assurance and report assurances and gaps in control to the Board and relevant Trust groups and Committees. Produce Audit Committee Annual Reports for the Trust. Keep an up to date schedule of planned external visits and update the Trust Board and Audit Committee on any assurances received. Oversee the running of the Operational Risk Group and Policy Approval Group. Develop and maintain external networks, promoting a positive image of the Trust. 22 jobs.sath.nhs.uk

23 POLICY DEVELOPMENT Develop the Trust wide approach to all policy development, ensuring that the system established meets NHSLA governance requirements. Develop a Policy sub-group to approve policies and guidelines. Be the system manager for 4Policy and develop the system to support dissemination and compliance monitoring. Be the trust lead on policy development, providing advice and guidance to staff. MANAGING THE COMPLIANCE AGENDA Prepare the Annual Governance Statement on behalf of the Chief Executive. Contribute to the annual reports for the Trust in line with national requirements. Oversee the FOI Policy, implementation, and monitoring of compliance. Produce regular monitoring and progress reports for Trust Committees as required. Provide support to clinicians/service managers on implementing governance in clinical areas. Promote the personal and professional development of all staff in governance, ensuring that regular education and training sessions are available on the implications and implementation of governance. Ensure the co-ordination of NICE guidelines dissemination. Ensure that the Trust participates in national initiatives where appropriate. Participate in training and development activities to develop the knowledge of managers in relation to governance including the senior manager s induction and training on risk management and governance. Develop, review and implement a wide range of corporate policies relating to risk management and clinical audit. Participate in specialty governance meetings and to support the development of governance across the Trust. Oversee the Trust s Clinical Audit agenda ensuring links to the Board Assurance Framework and to provide evidenced assurances. Oversee the Audit Committee Recommendation tracking process, liaising with internal audit. 23 jobs.sath.nhs.uk

24 PEOPLE MANAGEMENT Manage the staff and resources within the Assurance Team including the budgets and being an authorised signatory. Effectively manage the performance and continued personal development of the jobholders direct reports, including appraisals by: Setting, monitoring and reviewing individual objectives. Identifying learning and development needs. Agreeing personal development plans. To directly line manage the Clinical Audit Manager, Health and Safety Team Manager, Sustainability Manager, Community Involvement Manager, Communications Team and PA. COMMUNICATION & RELATIONSHIPS Liaise with staff and managers at all levels including Executive Directors and outside agencies. Ensure that effective systems of communication both written and verbal, formal and informal are established and maintained within areas of responsibility. Ensure information on governance and risk management issues is disseminated appropriately through the organisation. Present written and verbal reports to the Trust Board, senior management team, managers, and staff throughout the organisation in relation to operational and corporate governance issues. Be able to present and train all levels of staff in governance issues. Present written and verbal reports to the Trust Board, senior management team, managers, staff and patient groups on the national patient survey programme. This will include presenting information to large groups of staff / members of the public and can the audience can often be hostile. HEALTH AND SAFETY Provide leadership and direction to the Health and Safety Department. Develop a Health and Safety culture that meets the Trust s agenda for non-clinical risk management and enables the Trust to meet its Health and Safety duties and obligations. Ensure that the Trust meets its agenda and targets for Health and Safety and non-clinical risks including complying with the relevant Care Quality Commission and HSE legislation. Lead, guide and support the Health and Safety Team in developing and delivering the Trust s non-clinical risk management programme and Health and Safety Training programme in order to ensure compliance with health and safety legislation, procedures and standards. 24 jobs.sath.nhs.uk

25 CLINICAL AUDIT Oversee the annual clinical function for the Trust ensuring that if reflects local and national priorities and supports the Trust objectives, by providing a source of assurance to the Trust Board. Work with outside agencies to develop crossboundary audit programmes involving partner organisations in primary care. Undertake confidential audits of practice as required. SYSTEMS & EQUIPMENT Be the system manager for 4Risk - a web-based trust-wide system to hold all the Trust risk registers. Be the system manager for 4Policy - a web-based trust-wide system for policy dissemination and education. The jobholder uses the standard range of office equipment and systems as well as the hospital clinical information systems. GENERIC JOB STATEMENTS Trust Policies - As an employee of the Trust you have a responsibility to abide by all Trust policies and procedures, including Standing Orders and Standing Financial Instructions. Equality and Diversity - As an employee of the Trust you have a responsibility to ensure equal treatment for all employees, patients and carers regardless of age, disability, gender reassignment, marriage, maternity or pregnancy, race, religion or belief, sex and sexual orientation. Good Corporate Citizen - As an employee of the Trust you have a responsibility to adopt in yourself and encourage in others the highest standards of environmental behaviour, and to take measures to reduce the environmental impact of your own activities relating to energy and water usage, transport and waste. HEALTH & SAFETY As an employee of the Trust you have a responsibility to: Take reasonable care for your own Health and Safety and that of any other person who may be affected by your acts or omissions at work. Co-operate with the Trust in ensuring that statutory regulations, codes of practice, local policies and departmental health and safety rules are adhered to. Not intentionally or recklessly interfere with or misuse anything provided in the interests of health and safety. INFECTION PREVENTION AND CONTROL The prevention and management of acquired infection is a key priority for the Trust. Any breach of infection control policies is a serious matter which may result in disciplinary action. As an employee of the Trust you have a responsibility to: Ensure that your work methods are compliant with the Trust s agreed policies and procedures and do not endanger other people or yourself. Be aware of infection prevention and control policies, practices and guidelines appropriate for your duties and you must follow these at all times to maintain a safe environment for patients, visitors and staff. Maintain an up to date knowledge of infection prevention and control, policies, practices and procedures through attendance at annual mandatory updates and ongoing continuing professional development. Challenge poor infection prevention and control practices of others and to report any breaches, using appropriate Trust mechanisms (e.g. incident reporting policy). 25 jobs.sath.nhs.uk

26 INFORMATION GOVERNANCE AND CONFIDENTIALITY As an employee of this Trust you may gain privileged knowledge of highly confidential nature relating to private affairs, diagnosis and treatment of patients, information affecting members of the public, personal matters concerning staff, commercial confidences of third parties and details of items under consideration by this Trust. As an employee of this Trust you have a responsibility for creating accurate records of your work, for making entries into and managing all NHS records effectively in line with the Trust s Health Records and Corporate Records Management policies and procedures in order to meet the Trust s legal, regulatory and accountability requirements. You must maintain confidentiality by working within Information Governance standards and the Data Protection Act at all times. The unauthorised use or disclosures of patient or other personal information is regarded as gross misconduct. Such action will be subject to the Trust s Disciplinary Procedure and could result in a prosecution for an offence or action for civil damages under the Data Protection Act. PROFESSIONAL STANDARDS AND PERFORMANCE REVIEW As an employee of the Trust you have a responsibility to: Participate in statutory and mandatory training as appropriate for the post. Maintain consistently high personal and professional standards and act in accordance with the relevant professional code of conduct. Take responsibility for the maintenance and improvement of personal and professional competence and to encourage that of colleagues and subordinates. Participate in the Trust s appraisal processes including identifying performance standards for the post, personal objective setting and the creation of a personal development plan in line with the KSF outline for the post. SAFEGUARDING CHILDREN We all have a personal and a professional responsibility within the Trust to identify and report abuse. This may be known, suspected, witnessed or have raised concerns. Early recognition is vital to ensuring the patient is safeguarded; other people (children and vulnerable adults) may be at risk. The Trust s procedures must be implemented, working in partnership with the relevant authorities. The Sharing of Information no matter how small is of prime importance in safeguarding children, young people and vulnerable adults. PANDEMIC / OTHER EMERGENCIES In the event of a pandemic being declared, you may be required to adjust your days of work, hours of attendance, work base, and duties to support the delivery of services. As an employee of the Trust you have a responsibility to ensure that: You are familiar with and adhere to the Trusts Safeguarding Children procedures and guidelines. You attend safeguarding awareness training and undertake any additional training in relation to safeguarding relevant to your role. 26 jobs.sath.nhs.uk

27 STANDARDS OF BEHAVIOUR As an employee of the Trust you have a responsibility to act at all times in accordance with the Trust s values. INFORMATION GOVERNANCE AND CONFIDENTIALITY As a manager within the Trust you have a responsibility to ensure that the requirements of the Information Governance Toolkit are implemented throughout your area. STAFF ENGAGEMENT As a manager within the Trust you have a responsibility to engage with, listen to and involve staff in decisions that affect them and the design and delivery of the service that they provide. RISK MANAGEMENT As a manager within the Trust you have a responsibility to ensure that: Potential harm to patients, staff and visitors is minimised and that risks to achievement of business plans are controlled. An open reporting and learning culture exists for staff to report incidents and near misses and any remedial action is taken to prevent further recurrence. Undertake any other such duties as may be agreed with the Director Corporate Governance. Act in accordance with the Code of Conduct for NHS Managers. PROFESSIONAL DEVELOPMENT Take every reasonable opportunity to maintain and improve self-development including professional knowledge and competence. Participate in personal objective setting and review, including the creation of a personal development plan. WORKING CONDITIONS Usual office environment with a requirement to use VDU regularly. Whilst the post holder may be based at RSH, this does not preclude movement to another work base which may be necessary as a result of development or reorganisation of the Trust s services. To work flexibly to meet critical deadlines. PHYSICAL, MENTAL AND EMOTIONAL DEMANDS OF THE POST Effectively influence and negotiate with others in order to resolve complex and potentially contentious issues Will work to deadlines in preparing information for presentation and review. These can often change at short notice. Will experience regular interruptions with complex and non-routine enquiries which will often require an immediate response. The post requires frequent periods of prolonged concentration to check details, and write Board reports, other reports, policies and action plans. As the senior member of the function, to provide managerial, professional and emotional support to the Governance team, with particular responsibility for the senior staff. 27 jobs.sath.nhs.uk

28 This job description is represents a summary of the main responsibilities of the post and not an exhaustive list of duties to be undertaken. The duties may be redefined following discussion with the line manager. MANAGER POST HOLDER Signature Signature Date Date 28 jobs.sath.nhs.uk