Purpose: To hold day-to-day accountability for regulated activities and the quality, safety and experience of care. You will ensure compliance with CQC regulations and the Single Assessment Framework, lead clinical governance and operational delivery across private and NHS pathways (including ADHD assessment and medication titration), and drive continuous improvement aligned to contractual KPIs. Key responsibilities 1) Regulatory compliance & CQC relationship Be the CQC Registered Manager for HSMH locations/regulated activities, sharing legal responsibility with the provider. Maintain an up-to-date Statement of Purpose and make all statutory notifications/variations on time.
Evidence compliance with the Single Assessment Framework(5 questions; Quality Statements), embedding the we statements in policy, practice and evidence portfolios. Prepare for and host inspections. Lead compliance with the fundamental standards(e.g., Safe care & treatment, Good governance, Fit & proper persons employed, Staffing, Duty of Candour, Complaints). 2) Clinical governance, safety & risk Chair the Clinical Governance and Risk meetings; own the risk register, audits, action logs and learning system.
Ensure Duty of Candour is applied correctly, with compassionate communication, timely written follow-up and documented learning. Oversee incident reporting, triage and learning under PSIRF/LFPSE; ensure proportionate investigations and family/staff involvement Ensure robust safeguarding systems for adults and children (policy, training, supervision, referrals, multi-agency working). 3) Information governance & data quality Be the operational owner for Data Security and Protection Toolkit (DSPT)compliance; work closely with the DPO/Caldicott Guardian on IG, DPIAs, SARs and records management. Ensure accurate, complete and timely MHSDS submissions via SDCS Cloud for NHS-funded activity; drive data quality improvements.
4) Medicines & prescribing governance (including ADHD meds) Oversee safe medicines systems (policies, PGDs where applicable, e-prescribing workflows, storage, reconciliation, audits). Ensure compliance with Controlled Drugs legislation and work with the organisations CDAO/NHSE regional CDAO as required (e.g., CD incident reporting to cdreporting portal, LIN participation). Promote pharmacovigilance (encourage MHRA Yellow Card reporting and review of Drug Safety Updates). 5) NHS contract mobilisation & delivery Lead end-to-end mobilisation for new NHS ADHD pathways (SOPs, referral criteria, e-RS/onboarding, data flows, safeguarding and escalation protocols).
Monitor contractual KPIs and produce commissioner reporting packs; drive pathway efficiency (DNA reduction, waiting-time/throughput optimisation) while protecting quality. Liaise directly with contracted ICBs and be the point of contact for contract management 6) Operational excellence & patient experience Own the operating model for ADHD assessment and titration(triage, pre-assessment, diagnostics, shared-care transitions, physical health monitoring, e-prescribing). Embed the Accessible Information Standard and Equality Act reasonable adjustments; ensure inclusive, person-centred access and communication. Lead the complaints system end-to-end, ensuring timely responses, fair investigations and service improvements.
7) People leadership Line-manage and develop multidisciplinary teams; ensure safe staffing, safer recruitment (enhanced DBS, references, right-to-work), induction, supervision and appraisals. Maintain a live mandatory training matrix (safeguarding L3 adults/children, Prevent, BLS, IG, medicines safety, DoC). Foster a learning culture (freedom-to-speak-up principles, QI projects, audit programme). 8) Finance & resources Work with finance on budget stewardship, cost-neutral mobilisation plans, efficient clinic capacity and stock control for meds/diagnostics.
Oversee contracts with key suppliers (e-prescribing/pharmacy partners, EPR/telehealth vendors, labs). 9) External relationships Act as the senior operational link with ICBs/commissioners, GPs (shared-care), community pharmacies, safeguarding partners and CQC inspectors. Represent HSMH in system meetings; provide credible, data-driven updates and action plans. What success looks like (first 612 months) CQC inspection readiness with clear evidence packs mapped to Quality Statements.
As an organisation, or aim is always to achieve an outstanding rating NHS pathway mobilised on time with agreed KPIs delivered (access, safety, outcomes). Fully compliant DSPT; clean MHSDS submissions; visible data-quality uplift. Robust incident learning cycle in place (PSIRF approach), and exemplary Duty of Candour practice. Measurable improvements in patient experience (complaints down, compliments/NPS up) and staff engagement.