NCH&C is proud to be the first standalone NHS community trust in the UK to achieve an 'Outstanding' rating from the Care Quality Commission (CQC). Our focus is on continually improving the quality of care we offer to local people and on improving access to that care, helping people to move seamlessly from one service to another. Praising NCH&C's "compassionate, inclusive and effective leadership at all levels", the CQC observed that our staff are well supported to make positive changes and innovations. Norfolk Community Health & Care NHS Trust is committed to continuing to create a modern and inclusive work environment. As part of this commitment we actively promote flexible working opportunities where possible, to meet the needs and wishes of our workforce to maintain and improve their wellbeing. The trust offers a range of flexibility, including flexible working patterns, and we would encourage you to discuss this with the recruiting manager before or during the application process if this would interest you. We welcome applications from people who share our values and can help us deliver outstanding care in our local community. Before applying for this vacancy, please make sure you\'re familiar with ongoing GOV.uk sponsorship eligibility criteria which will impact the organisations ability to provide sponsorship, whether this is currently or in the future. Specifically for band 3 roles within healthcare please be aware of the salary threshold required for a certificate of sponsorship to be granted, and that unfortunately overseas applicants who are new to care will not reach the minimum salary threshold to obtain a certificate of sponsorship and therefore your application will be withdrawn.
An exciting opportunity for a Governance and Quality Support has become available. This role covers the Norwich Place including Specialist Services, Community Nursing and Therapy and works closely in collaboration with the central corporate clinical governance and quality teams. The main base for this post holder will be at Colman Hospital but travel will be required within Norwich teams. One day per week all Place Governance and Quality Supports will work together at one of the NCH&C bases on a rotation basis.
The role of Governance and Quality Support will support the delivery of excellent standards of quality and ensure robust governance processes are in place in the teams across the Norwich Place. This will include a range of governance activities to monitor, analyse and support delivery of systems and processes in line with local and national requirements. The post holder will support the delivery of excellent standards of quality, care and ensure robust governance processes are in place. This will include a range of governance activities to monitor, analyse and support delivery of systems and in line with local and national requirements.
The post holder will require engagement with internal and external stakeholders and include continued improvement on areas such as effective complaint handling, patient feedback management and investigation processes. The monitoring of risk and improvements to quality standards, systems and processes will be a core component of the role. The post holder will be responsible for monitoring compliance against a range of national and local standards including but not limited to Care Quality Commission (CQC) and National Institute for Health and Care Excellence (NICE) guidance as well as local quality standards and ongoing national and local audit programmes. To maintain relationships and shared learning across the Place and with the central governance team, ensuring governance activities are in line the trust policy and agreed processes.
Responsibilities
1. To be competent in the trust governance processes and effectively communicate and embed those across the Place and services.
2. To monitor quality and governance processes across Place and to work closely with other Governance and Quality Supports to ensure standardisation.
3. To maintain a good knowledge of Place services and functions.
4. Support all relevant Place services and departments in ensuring compliance with core NHS standards including but not limited to Care Quality Commission (CQC) guidance, National Institute for Health and Care Excellence (NICE) and the Department of Health (DoH).
5. Co-ordinate the compilation of the regular Place governance reports and provide support in the compilation of other governance related reports including for example: Infection Control report and Safer Staffing reports and ensure timely submission.
6. To deputise as chair, where needed, at the local risk, quality and governance meetings and to act as the Place representative at trust meetings where appropriate.
7. Collate all required information and ensure timely submission of accurate data to inform the internal and external assurance frameworks.
8. Initiate the investigation of incidents and complaints in a timely manner and manage incident reporting system and appropriate escalation of incidents. To support staff in the collation and submitting of After Action Reviews and Duty of Candour responses within timescales as per trust policy.
9. To support the local subject matter experts (SMEs) in the review of raised incidents ensuring they are finally approved in the organisational incident reporting system.
10. To support the central governance team in the quality checking of finally approved incidents as per a planned quality checking programme, ensuring improvements and actions are implemented where necessary and staff are supported in learning and development related to finally approving incidents.
11. Promote and encourage an open reporting and learning culture within the trust.
12. Develop own knowledge and practice and actively assist others to continually professionally develop.
13. Demonstrate and support a working environment and culture that actively improves health, safety and security.
14. Support and enable equality, diversity and rights.
15. Prioritise and communicate key issues to the Quality Matron, Clinical Quality Director or Senior Management Team in line with needs of the trust.
16. To continually review established processes and inform process owners of potential improvements and changes as and where necessary to support the trust in delivery of objectives in the most efficient manner.
17. Clinical Governance
18. Assess, monitor and review performance to ensure full compliance both nationally set and locally set standards and targets.
19. Together with the Quality Matron, support the preparation for assessments from NHS regulators such as CQC and local commissioners as and where necessary
20. To work closely with the Quality Matron in leading the accurate and timely reporting and provision of information as and when requested by NHS regulators such as CQC and local commissioners.
21. Support the efficient co-ordination of the clinical governance related meetings and forums to ensure they function effectively, according to an annual plan and in line with trust assurance framework.
22. To support the implementation of changes to ensure compliance with national and local standards.
23. In collaboration with the Quality Matron, review and update relevant strategies, policies and procedures as required.
24. Support local SMEs with the update of specific policies and associated documentation (such as but not limited to, care plans, patient leaflets, intranet pages, website information etc.
25. Proactively manage the incident reporting system, ensuring all incidents are investigated in a timely manner and the lessons learnt are shared with all relevant teams and team members.
26. To deliver work supporting local and organisational quality improvement, offering advice and support to others, whilst ensuring continuous governance compliance throughout the trust.
27. Responsible for effective dissemination and central reporting of all issued alerts and collation of actions required
28. Manage and co-ordinate clinical and non-clinical risk activities ensuring compliance with relevant regulatory bodies including where needed creation of action plans and mitigation proposals to support organisational management of identified risks.
29. Ensure appropriate reporting, investigation and management of incidents is undertaken in accordance with documented processes and requirements and where necessary develop and devise procedures/processes and local policies, as necessary.
30. Co-ordinate the dissemination, integration and implementation of corporate and local policies and procedures. Support colleagues to contribute to appropriate policies where appropriate, and ensure they are reviewed within the required time frames.
31. Adopting a multi-disciplinary approach, in conjunction with colleagues, work to develop an organisational culture which encourages professionals to review practice, report untoward incidents and share lessons learnt without fear of recrimination or censure.
32. Ensure that the views of patients and customers are used to guide and inform the provision of services through patient forums, engagement with patient representative groups, dissemination of feedback form questionnaires, complaints etc.
33. Ensure that relevant and appropriate information, advice and support is available to all service users and stakeholders.
34. To support the Place in improving Friends and Family Test (FFT) scores and feedback through implementation of actions and learning as and when identified. This will include close working with the Lived Experience and Co-Production Manager and associated roles ensuring organisational learning and development is implemented where necessary and appropriate.
35. To support the local escalation of PALS enquiries where appropriate.
36. Health & Safety
37. Support the Place in the delivery of local health and safety objectives with an aim to reduce organisational risk.
38. Work closely with the Quality Matron to ensure that appropriate and necessary audit activity is completed in line with both the annual corporate and local plan, prioritising audits against key performance indicators.
39. Ensure that the local annual audit plan is devised and delivered, and actions and outcomes are implemented and where appropriate monitored through a robust action plan.
40. Oversee audit activity to ensure compliance within the clinical departments throughout the Place.
41. Engage with National Audit Programmes as and where necessary and ensure timely submission of data as relevant to hospital practices.
42. To inform and advise the trust and its employees about their obligations to comply with local and national standards set by organisations such as but not limited to the Care Quality Commission and Department of Health.
43. To be the first point of contact for employees regarding governance and quality matters within the Place, seeking support where required.
44. To support compliance with NHS legislation and codes of practices providing guidance and advice where necessary influencing conversations (following multi-faceted scenarios and applying the relevant advice).
45. To process complex situations and scenarios, analysing and interpreting the information from multiple sources, producing and presenting reports on a regular basis including options appraisals and making recommendations for a range of meetings both internal and external to the organisation including but limited to Risk Group and relevant commissioner led service review meetings.
46. Responsible for advising on complex governance and quality compliance, incident, patient safety or risk management matters, ensuring appropriate and timely escalation where required to subject matter experts across the trust to support with the provision of advice and guidance.
47. To communicate with patients, carers and stakeholders to support complaint resolution and investigations as well as to gather feedback to embed learning.
48. Using analytical skills and subject knowledge, to work within trust policy and national and local guidance, to support the trust to remain compliant with the relevant guidance and best practice.
49. Responsible for accessing information from a range of internal and external sources, and including risks, incidents, complaints and patient feedback, interpreting and applying best practice to make recommendations to the trust. This will include preparing and presenting reports.
50. Responsible for supporting the creation of reports and information data sets into standard organisational meeting templates to support the governance agenda and demonstrate Place compliance with set standards.
51. The effective use of SystmOne and Datix systems to support with the management of complaints, investigations and external information requests.
52. Equal Opportunities - We are an equal opportunities employer and welcome all applications irrespective of age, disability, gender, sexual orientation, race or religion. Additionally, people with disabilities that fall under the Disability Confident Scheme will be offered an interview providing they meet the minimum criteria for the post (outlined in the Person Specification). All sites are Smoke Free.
53. If you need this application in an offline format, please let us know.
54. Immigration Status - Norfolk Community Health & Care NHS Trust is a diverse employer and welcomes all job applications. However, potential applicants should note that although the Trust is registered with the Home Office as a sponsor organisation for migrant workers, sponsorship can only be offered against Skilled Worker visas. If you are an applicant from outside the UK and do not already hold a self-gained right to work, we recommend you check the Home Office eligibility requirements before making an application.
55. Please note: Although we are a registered sponsor organisation, we are unable to offer sponsorship for some job roles, and this will be identified through filtering questions at the start of any job application on the Trac recruitment system.
56. Redeployment - Please note that in the first instance priority for this vacancy will be given to NCH&C staff who are on the Trusts Redeployment Register.
57. DBS - If this post is subject to a Disclosure and Barring Service (DBS) check and you are not a current employee of Norfolk Community Health and Care NHS Trust or being recruited as an Apprentice then the cost of the DBS check will be automatically removed from your first month\'s salary. However if you are registered with the update service this may not be required.
On April 1st 2025, the Boards of Norfolk Community Health and Care NHS Trust and Cambridgeshire Community Services NHS Trust will come together to deliver services as a group, with a singular board operating across both organisations. Both trusts are high performing specialist community health and care providers working in the East of England. Both have a strong track record, with the highest ratings from the Care Quality Commission, best in class NHS staff survey outcomes, and a decade of experience in innovation and clinical development. The group model provides health and care services to a population of 3.2 million in their homes and neighbourhoods. We provide care that supports people from the very beginning to the very end of their lives. We will remain two separate employers until further notice, and this role being advertised will be employed by Norfolk Community Health and Care NHS Trust.
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