Compliance and Governance Manager

We are committed to supporting maintaining and improving our 'Good' CQC rating. This role is pivotal to this and we are looking for an experienced CQC Compliance and Governance Manager. We are seeking a CQC Compliance Manager to join our Nursing and Quality Directorate. You will report directly to the Deputy Director of Nursing and Quality and will oversee all CQC activity. Working alongside Directors and Senior Leads this is an excellent opportunity to support the Trust in a critical post with the ability to influence and support our services in assuring our fundamental standards of care are being met.

Main duties of the job

This role will provide strong, visible professional focus on ensuring the improvement of the Trust's CQC governance and regulatory focus.

This will involve working across the Divisions, Directorates and corporate specialists to ensure compliance and improvement at service level, supporting the implementation of quality improvement plans.

Ensure strategies are in place to deliver measurable and sustainable improvement in quality and safety in line with local and national best practice standards and CQC regulatory standards.

Support the management of CQC regulation (inspection and regulation) across the Trust.

Lead the clinical governance agenda taking the lead to ensure that robust systems are in place within an improvement-focused infrastructure.

Provide oversight to the Head of Service with the policy and procedure framework as required.

In line with the Trust's being a provider in MH & LD services, the post holder will be expected to support any service developments in respect to Regulation and Standards.

Responsible for the line management of the Governance & Compliance Coordinator and the management of the corporate CQC database.

About us

As an employee of Derbyshire Healthcare NHS Foundation Trust, you are required to adhere to the Trust's overriding value of 'To make a positive difference in people's lives by improving health and wellbeing'. In recognising both the values expressed in the NHS Constitution and the Trust Values:

People first - We work compassionately and supportively with each other and those who use our services. We recognise a well-supported, engaged, and empowered workforce is vital to good patient care.

Respect - We respect and value the diversity of our patients, colleagues and partners and support a respectful and inclusive environment.

Honesty - We are open and transparent in all we do.

Do your best - We recognise how hard colleagues work and together we want to work smarter, striving to support continuous improvement in all aspects of our work.

Job responsibilities

Principal Duties and Responsibilities

1. Quality Standards and Assurance

Support the management of the self-assessment compliance system for the Trust which rates compliance against the CQCs fundamental standards of care. This includes making recommendations for database development, running routine reports, and creating reports to monitor data around quality standards for both service and Divisional use.

Ensure compliance with Care Quality Commission and other regulatory standards.

Contribute to writing Board level Committee reports on a quarterly basis as a minimum, providing quantitative and qualitative information.

Where gaps or threats to compliance are identified, the post holder will support the development of an improvement plan and monitor to closure, ensuring quality improvement actions are both complete and embedded.

Manage the Trust's Internal Quality Review Process, the Fundamental Standards of Care to ensure compliance of external regulatory standards reviewing the assessments within divisions as part of the self-assessment system.

Write and present Quality Review reports following a review visit. This includes making judgements regarding standards of care against standards set by a regulatory body. The report and their presentation may include sensitive information.

Support the Matron/ASM to update an accurate registration portfolio of CQC locations and registered activities.

Provide advice and support to Directorates on compliance in relation to the understanding of the Trust's Values and associated key lines of enquiry that the Trust are assessed against.

Monitor action plans required because of regulatory compliance visits or inspections, seeking assurance of quality improvement.

Seek opportunities with corporate specialists across the Trust to create synergies across work streams to ensure an integrated, streamlined approach to corporate work programmes.

Support the implementation and delivery of the Quality strategy for the Trust.

Prepare information for and attend routine CQC Inspector meetings with the Executive Director of Nursing, AHP, Quality and Patient Experience.

Assist the Executive Director of Nursing, AHP, Quality and Patient Experience in the compilation of requested information from the regulator and timely submission of such requests.

Coordinate the regulators' visits announced and unannounced and ensure the set standard procedures are followed.

Monitor and track queries, concerns, and complaints received from the regulator and assist the Executive Director of Nursing, AHP, Quality and Patient Experience in compiling appropriate responses and submitted to the regulator in a timely manner.

Deputise for DDoN as required in forums related to the CQC such as CQC Oversight Group.

Person Specification

Qualifications

• Registered Mental Health Nurse or Registered Learning Disability Nurse
• Educated to Diploma/Degree Level (i.e. Dip HE Nursing)
• NVQ Assessor, CG 730 or equivalent

Experience

• Recent and relevant post registration clinical expertise that includes core competencies around NMC Nurse Competencies

Experience

• Extensive relevant experience of working at a specialist level in compliance and assurance in an NHS organisation.

Experience

• Have highly developed specialist knowledge of how CQC standards and other regulatory standards impact on clinical services and how to interpret them to maximise clinical outcomes.

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.

£46,148 to £52,809 a year, pro rata (subject to AfC job evaluation)