Quality Governance (Audit, Compliance and CQC) Manager

Transcription

1 Quality Governance (Audit, Compliance and CQC) Manager Service Location Central Office Worcester Cranstoun is a charity empowering people to live healthy, safe and happy lives. Our skilled and compassionate teams work with service users, families and communities, helping them to make positive changes. We offer a wide range of services across England, including communitybased outreach, treatment and recovery, detox, supported housing, and specialist services for young people and families and carers. We ve been making a difference since 1969 by combining our expertise with innovative approaches, and putting people at the heart of what we do. 1

2 JOB DESCRIPTION Job purpose / Context: The Quality Governance Manager will drive forward the quality of care in our services, by leading on a range of quality governance activities, including the Group s audit cycle; compliance to clinical and best practice standards; and compliance to regulatory frameworks. Responsible to: Director of Care, Quality & Governance Responsible for: Audit, Compliance and CQC Coordinator The Quality Governance Manager will work alongside the Incident & Policy Manager and Director of Care, Quality and Governance and will lead on the following work streams. 1. Auditing Responsible for the delivery of the Cranstoun Group s audit framework including clinical and thematic audits, Periodic Service Reviews and locally led audits in line with CQC regulatory requirements. Process and analyse data from audits and report on themes and trends to a range of audiences. Create action plans from audits and other quality assurance activities, giving feedback to staff at all levels to ensure the quality and safety of care delivered. Work with Area Managers and Directors to ensure action plans are completed. Responsible for the development of the Cranstoun Group s annual audit cycle in conjunction with the Clinical Director, Incident & Policy Manager and other staff as appropriate. 2. NICE and clinical compliance Work in collaboration with the Incident and Policy Manager to ensure compliance with NICE (National Institute for Health & Care Excellence) standards, clinical standards and best practice. Monitor new and emerging NICE, Department of Health and Public Health England guidance, and ensure these are reflected in the Cranstoun Group audit cycle. Oversee compliance with infection control practice, monitoring and training in line with Group policy. Work with the Director of Care, Quality & Governance and the Clinical Director to agree Clinical audit frameworks and report compliance issues. 3. Safeguarding Support the Director of Care, Quality & Governance in their role as Senior Safeguarding Officer. Provide expertise and advice on safeguarding issues and ensure internal audit s measure and monitor compliance with Group safeguarding policies and guidelines. 2

3 Implement, maintain and monitor Cranstoun s Safeguarding Quality Assurance Framework and reporting cycle. Keep up to date with latest statutory safeguarding requirements and best practice, and communicating developments across the Group. Ensure safeguarding policies are up to date, working in conjunction with the Incident and Policy Manager. 4. CQC Support Registered Managers to ensure compliance with the CQC Regulatory Framework and assist with registration requirements. Ensure the auditing cycles are implemented and assist with analysis of data, reporting patterns and trends to the Director of Care, Quality & Governance. 5. Information Governance Tool Kit Delivery of compliance and maintenance of the Data Security and Protection Toolkit (formally known as the Information Governance Tool Kit). Oversee General Data Protection Regulation (GDPR) compliance with the Data Protection Lead, Director of Care, Quality & Governance and Executive Director of HR & Governance. Ensure audits are undertaken in line with requirements for GDPR. 6. ISO Accreditations Responsible for ensuring compliance with ISO 9001 quality standards, including the maintenance and implementation of Cranstoun s Quality Management System and other quality accreditation systems as required. 7. Governance framework Ensure that the Cranstoun Group quality governance framework underpins all working practices within the organisation. Work closely with the Health, Safety & Facilities Manager to ensure compliance to the annual health and safety audit framework and to identify trends across services. 8. Other duties Work closely with the Incident & Policy Manager to feed into policy reviews and review incidents and complaints. Undertake investigations using Root Cause Analysis methodology and devise action plans as necessary. Undertake any additional duties as may be reasonably required and requested by the Director of Care, Quality & Governance. 3

4 PERSON SPECIFICATION Qualifications Educated to degree level, or equivalent. Recognised governance qualifications or suitable demonstrable experience of managing governance systems and processes i.e. Advanced Certificate in Health Service Governance. IRCA certified ISO 9001:2015 internal auditor training is desirable Experience Experience of working within the health and social care field, preferably within a substance misuse setting. Experience of working with people from a range of social and cultural backgrounds. Experience of managing governance activities within a health care or corporate setting. Experience of quality and clinical auditing, monitoring and measurement activities. Experience of undertaking investigations into serious incidents using a Root Cause Analysis methodology, and making recommendations to improve service provision. Experience of managing compliance to the NHS Information Governance Toolkit, now known as the Data Security & Protection Toolkit. Abilities and attributes Ability to drive forward quality improvements across services. Ability to review, recommend and facilitate service improvement programmes. Willingness to support a range of services and travel to different locations. Ability to work with a wide range of professionals and agencies. Ability to develop and implement effective monitoring mechanisms. Ability to manage and understand budgets and financial information. Skills Excellent written and verbal communication skills. Ability to present complex and sensitive information to a range of audiences. Confident in multi-disciplinary / agency discussions and meetings. Ability to build positive relationships with all stakeholders. Excellent IT skills. Knowledge Understanding of the UK Drug Strategy and current Social / Health Policy reforms. Knowledge of regulatory bodies, including in depth knowledge of Care Quality Commission Regulations. Knowledge of quality governance in a health care setting Advanced knowledge of safeguarding legislation and best practice. In depth knowledge of statutory safeguarding requirements for adults and children, including the Mental Capacity Act

5 Understating of Information Governance and GDPR requirements. Understanding of Quality Management Systems, i.e. awareness of ISO 9001:2015. Diversity Understanding, awareness and commitment to the promotion, and support of all aspects of diversity both in the workplace and external environments. Demonstrable experience of working to policy, procedure and best practice within all aspects of diversity. Commitment to the rights of service users to determine their own choices. 5