Towards Outstanding Regulatory Compliance Improvement Lead
To provide expert knowledge and training to help build an understanding of, support for, and action in, quality Improvement, innovation and compliance monitoring as a means of improving the performance and decision
- making within the Trust.
Keep up to date with regulatory new inspection regimes (e.g.
CQC, NHSE, Ofsted etc.) for Mental Health & Learning Disability services and to interpret any changes in the context of quality improvement programmes and initiatives to ensure alignment is maintained to outstanding characteristics of the regulatory bodies.
To compare and analyse all Trust wide improvements, aligning these to the regulatory domains (i.e.Safe, effective, caring, Responsive & Well Led for CQC) and provide expert opinion regarding any gaps, required areas of focus and to oversee remedial actions, whilst ensuring robust reporting via relevant Trust groups and committees.
To have a Trust wide overview of all service self-assessments (Heat maps) and provide expert analysis and sensitive challenge to ensure there is evidence to support where compliance is reported to be achieved / excelling.
To develop and deliver programs of work and training to clinical and non-clinical staff in order to assist and to apply leadership skills which will influence and motivate services to undertake compliance/governance related activities and strive towards outstanding services in every area of the Trust, using a variety of working methods.
To lead the development and monitoring process for compliance work/action plans/trackers which focus on achieving outstanding services, ensuring that robust assurance is provided and regularly reported to Trust Board/ Committees/Groups.This involves critical analysis and where appropriate challenge to services to ensure robust assurance is in place.
To be highly self-motivated and to autonomously manage and prioritise workload; making independent decisions about next steps / improvement requirements within services.
Provide professional challenge and where appropriate; take pro-active improvement action to maintain compliance with all key regulatory domains throughout the Trust, ensuring that concerns / barriers are escalated in a timely manner and are also reported via the Trusts Quality Assurance Board.
To provide clinical leadership on the programme of announced and unannounced quality visits, and quality assurance audits so that all Trust services can identify any concerns and provide specialist advice which will ensure that concerns are addressed and improvement trajectories towards outstanding are in place.
To lead the development and implementation of robust outcome reports from evidence reviews related to the Care Quality Commission registration requirements and ensure any exception reports with areas of improvement have a clear trajectory of achieving outstanding services.
To work closely with colleagues in communications and engagement, taking a lead on ensuring messaging is consistent, comprehensive and effective and clearly represents our ambition to be outstanding in all that we do and how we do it.Take responsibility for maintaining the upkeep of the Trust Live QI reporting system to ensure all Towards Outstanding quality improvement initiatives maintain momentum with dedicated QI support and guidance where required.
Where necessary ensure that action plans from external visits are monitored via relevant Trust committees locally, collating evidence of implementation and compliance, with clear trajectories towards achieving outstanding services.
To provide expert advice and training to services around quality improvement methodology and actively encourage Quality Improvement initiatives, ensuring they are aligned to all core CQC Services and referenced against the relevant Key Line of Enquiry.
To be responsible for the monitoring and the delivery of CQC towards Outstanding improvement plans throughout the Trust, providing assurance to Quality Assurance Board.Support Bi-weekly Quality Assurance Board meetings and take responsibility to promote effective engagement with the Directorate leads and Heads of Departments to ensure services have sufficient knowledge and understanding of regulatory requirements and Quality improvement methodologies.
Lead monthly meetings with Directorate Leads to review towards outstanding improvement plans and RAG rating of actions- ensuring that robust assurance is in place and can be reported on.
To ensure that reports presented to Trust Board/other Committees are of a high quality and provide robust assurance, with clear trajectories of achieving outstanding service, Work with all levels of staff throughout the Trust
- including the Matrons and Service Managers, Executive Leads and Directorate leads.
Ensure regular "horizon scanning" to identify changes to existing standards and assist in identifying innovations and improvements in other organisations and areas of nationally showed cased best practice.
Actively create opportunities to engage with patients and carers as part of quality assurance and towards outstanding activities.To ensure that all standards set by external agencies e.g.
Care Quality Commission (CQC), NHS Improvement, Commissioners etc.
are implemented within the Trust, ensuring the Trust is up to date with knowledge regarding current requirements and has processes in place to support achievement of such.
Ensure that all required governance policies, protocols, procedures, and strategies are in place, up to date and are evidence based, this includes proactively monitoring for changes in national/local guidance (incl.
NICE) and keeping the Policy Review Group abreast of any changes that may impact on Trust-Wide Policies.
To lead the review of Trust wide policies,to ensure that they are current, reflect national guidance and current legislation and are compliant with relevant Trust wide standards.
Assess the impact of new policies on CQC compliance and comment on draft policies to ensure the authors are aware of the impact.
To deputise for the Quality Improvement Manager in their absence and where appropriate take responsibility for the Quality Improvement Teams financial budget.
Key Relationships: The role will receive line management from the Trusts Quality Improvement Lead, who will also provide guidance and supervision in quality improvement methodologies.
Other key relationships are:- The Trusts corporate governance team, with a particular alignment to the Trusts Quality Assurance and Improvement Manager, where close, partnership working will be essential to the success of the Trusts outstanding regulated compliance.
The operational services team leads and senior leadership teams.