The Compliance, HR &Operations Manager is responsible for ensuring the effective, compliant, andefficient operation of Hughenden Valley Surgery. The role provides leadershipacross regulatory compliance, human resources, operational performance, governance,risk management, workforce planning, and business administration.
The post holder will ensure thepractice meets all statutory, contractual, and regulatory requirements,including those established by the NHS, the Care Quality Commission (CQC),Information Commissioners Office (ICO), Health and Safety Executive (HSE), andother relevant bodies. They will also support the development of a positiveworkplace culture and drive continuous improvement in patient services andoperational efficiency.
Main duties of the job
Key Responsibilities
1. Compliance, Governance & Risk
* Lead compliance with CQC standards, NHS guidance, GDPR, DSPT, and other regulatory requirements.
* Maintain policies, governance frameworks, compliance records, and audit readiness.
* Manage risk registers, incidents, complaints, business continuity, and health & safety compliance.
2. Human Resources
* Support workforce planning, recruitment, onboarding, and retention.
* Ensure compliance with employment, DBS, right-to-work, and NHS standards.
* Manage employee relations, appraisals, training, wellbeing, and HR records.
3. Operations Management
* Oversee day-to-day non-clinical operations, including reception and administration.
* Monitor KPIs, service performance, contractual targets, and enhanced services.
* Manage premises, facilities, contractors, maintenance, and operational resilience.
4. Quality Improvement & Patient Experience
* Lead quality improvement programmes and service development initiatives.
* Analyse patient feedback, complaints, and outcomes to drive continuous improvement.
* Support budgeting, procurement, supplier management, and contract compliance.
* Contribute to business planning and ensure value-for-money.
* Oversee digital systems, IT infrastructure, cyber security, and D AI adoption, andinformation governance.
* Lead management of EMIS Web, Docman, NHS Smartcards, data quality, and reporting.
About us
Welcome to our practice! We are dedicated toproviding high-quality healthcare in a friendly and compassionate environment.Our team of experienced doctors, nurses, and support staff are committed toensuring your well-being with a focus on personalised care. We are also atraining practice, dedicated to supporting the development of future healthcareprofessionals. We provide a full general medical service to our communityincluding but not limited to maternity, family planning (including implants andcoils), menopause advice, cytology, immunisations, travel vaccinations, minor surgery,and corticosteroid joint injections.
Job responsibilities
Key Responsibilities
1. Compliance & Governance
Regulatory Compliance
* Lead and maintain compliance with CQC Fundamental Standards.
* Ensure readiness for CQC inspections and external audits.
* Monitor changes in healthcare legislation, NHS guidance, and regulatory requirements.
* Develop, review, and implement policies, procedures, and governance frameworks.
* Maintain compliance registers and evidence portfolios.
Information Governance
* Act as the practice lead for information governance compliance.
* Ensure compliance with:
* UK GDPR
* Data Protection Act 2018
* NHS Digital requirements
* DSPT (Data Security and Protection Toolkit)
* Coordinate annual submissions and audits.
* Maintain the practice risk register.
* Lead incident reporting and investigation processes.
* Monitor significant events, complaints, and learning outcomes.
* Support business continuity and disaster recovery planning.
Health & Safety
* Ensure compliance with health and safety legislation.
* Coordinate risk assessments and workplace inspections.
* Maintain fire safety, infection control, and occupational health compliance.
* Liaise with external contractors and advisors.
2. Human Resources Management
Workforce Planning
* Support recruitment and retention strategies.
* Identify workforce requirements aligned with patient demand and service delivery.
* Develop succession planning initiatives.
Recruitment & Onboarding
* Manage end-to-end recruitment processes.
* Locum Staff recruitment process.
* Ensure compliance with:
* Safer recruitment requirements
* Right-to-work legislation
* DBS requirements
* NHS Employment Standards
* Coordinate induction programmes.
Employee Relations
* Advise managers on employee relations matters.
* Manage disciplinary, grievance, absence, and capability procedures.
* Facilitate conflict resolution and staff wellbeing initiatives.
* Promote equality, diversity, and inclusion.
Performance & Development
* Coordinate annual appraisal processes.
* Maintain mandatory training compliance.
* Identify training needs and development opportunities.
HR Administration
* Ensure HR systems and documentation remain compliant.
* Produce workforce reports and metrics.
3. Operations Management
Practice Operations
* Oversee day-to-day non-clinical operations.
* Ensure smooth running of reception, administration, and support functions.
* Develop operational procedures to improve efficiency and patient experience.
Service Performance
* Monitor and report on key performance indicators (KPIs).
* Support achievement of contractual obligations and quality targets.
* Assist in delivery of enhanced services and local commissioning requirements.
Business Continuity
* Maintain and test business continuity plans.
* Coordinate emergency preparedness activities.
* Ensure operational resilience.
Facilities Management
* Manage premises-related contracts and service providers.
* Oversee maintenance schedules and compliance inspections.
* Ensure a safe and welcoming environment for patients and staff.
4. Quality Improvement & Patient Experience
* Lead continuous quality improvement initiatives.
* Analyse patient feedback and complaints.
* Support implementation of service improvements.
* Coordinate quality assurance programmes.
* Contribute to annual practice development plans.
* Support financial planning and budget monitoring.
* Assist with procurement and supplier management.
* Monitor service contracts and compliance obligations.
* Contribute to business cases and operational planning.
* Ensure value-for-money principles are applied across operations.
Oversee the effective management, security, and optimisation of the practices digital systems and IT infrastructure.
Act as the operational lead for EMIS Web, Docman, NHS Smartcards, and other practice management systems, ensuring appropriate access controls, compliance, and system governance.
Liaise with NHS and external IT providers to support system performance, cyber security, software updates, and digital service improvements.
Support data quality, reporting, and information governance requirements, including compliance with NHS Digital standards and the Data Security and Protection Toolkit (DSPT).
Identify and implement opportunities for digital transformation, automation, and AI-enabled technologies to improve operational efficiency, workforce productivity, and patient experience.
Lead and support the management of patient complaints, ensuring timely investigation, appropriate response, learning outcomes, and compliance with NHS complaints procedures and practice policy.
Person Specification
Qualifications
* Degree-level qualification or equivalent experience in:
* oHuman Resources
* oBusiness Administration
* oOperations Management
* CIPD Level 5 qualification (or working towards).
* Evidence of continuous professional development.
* Experience within General Practice.
* Experience with Primary Care Networks (PCNs).
* Experience managing NHS contracts.
* Experience supporting CQC inspections rated Good or Outstanding.
* Experience with workforce planning in primary care settings.
Experience
* NHS primary care operations.
* Information governance and UK GDPR.
* Health and Safety legislation.
* Equality, Diversity and Inclusion requirements.
* experience in healthcare, primary care, NHS, or regulated environments.
* Experience managing compliance and governance frameworks.
* Experience in HR management and employee relations.
* Experience leading operational improvement initiatives.
* Experience developing policies and procedures.
* Experience managing audits and regulatory inspections.
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.
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