Job overview
As part of the national Community Diagnostic Centre (CDC) Programme, all CDCs are required to achieve accredited standards for their modalities within two years of becoming operational. The Accreditation Manager will be responsible for leading the CDC sites through this process within the required timeframe. In BLMK, the North Bedfordshire CDC in Bedford became operational in October 2025.
The successful applicant will lead the development, implementation and embedding of a robust accreditation framework for the CDC service. Establishing a programme of continuous improvement and ensuring delivery of key performance standards are central to the role. Supporting modality leads in creating and maintaining their individual SOPs will form a core part of the responsibilities.
The post holder will ensure that all clinical areas have effective systems in place to monitor and maintain compliance with required standards of practice. They will lead on establishing a strong clinical audit programme and work closely with teams to ensure quality improvement projects are developed and delivered at departmental level where needed.
Main duties of the job
1. Undertake a full gap analysis of each service to assess current status and identify actions required to meet regulatory standards.
2. Develop a comprehensive roadmap outlining the steps and timelines needed to achieve accreditation across the service.
3. Design and deliver presentations on highly complex issues to a wide range of stakeholders, including ICB and Board‑level audiences.
4. Promote strong leadership and staff engagement to ensure completion of the full audit schedule.
5. Lead all UKAS and regulatory assessment and audit processes.
6. Ensure the Quality Management System (QMS) is fully implemented, maintained and embedded across all relevant areas.
7. Develop, review and secure sign‑off for local SOPs and policies, ensuring compliance with all relevant regulations (e.g., infection control, health and safety, manual handling).
8. Produce the Quality Manual required to support the accreditation process for the services.
9. Ensure the QMS functions effectively by establishing, managing and maintaining regular quality meetings.
Working for our organisation
Bedfordshire Hospitals NHS Foundation Trust provides hospital services to a growing population of around 700,000 people living across Bedfordshire and the surrounding areas across two busy hospital sites in Bedford and Luton. Both hospital sites offer key services such as A&E, Obstetrics-led Maternity and Paediatrics. You will be joining a friendly, high performing Trust committed to ensuring the health and wellbeing of staff. As one of the largest NHS Trusts in our region you will have access to a programme of high quality training and development to help you grow your career. The Trust continues to be committed to delivering the best patient care using the best clinical knowledge and technology available.
We not only recruit based on qualifications and experience - we recruit individuals who demonstrate the behaviours which underpin our Trusts core values. We achieve this by using values based recruitment. We are dedicated to making our recruitment practices as inclusive as possible for everyone, we are committed to promoting equality and diversity, and creating a culture that values differences.
Please note that vacancies may close prior to the advertised closing date when sufficient number of applications have been received. All new staff will be subject to a probationary period covering first 6 months in post. Travel between hospital sites may be required. Please review all documents attached to ensure you familiarize yourself with all requirements of the job.
Detailed job description and main responsibilities
10. Ensure Trust policies and procedures are consistently followed and actively promoted.
11. Confirm that local procedures are aligned with Trust policies and support safe, effective practice in compliance with CQC, RCR and other regulatory standards.
12. Lead and support staff through the QSI accreditation process, including review, change management and implementation activities.
13. Lead the development and delivery of projects designed to enhance clinical practice and improve patient care.
14. Provide expert advice and take responsibility, where appropriate, for developing and reviewing CDC policies and procedures, contributing to wider policy development and decision‑making.
15. Design and deliver training programmes for staff involved in the accreditation process, including audit methodology and related competencies.
16. Act as a visible clinical leader, guiding the workforce to deliver kind, safe and high‑quality care.
17. Lead the strategic approach to achieving Quality Standard accreditation across all relevant areas.
18. Provide leadership and act as a role model for clinical and non‑clinical staff, offering professional guidance at both local and national levels.
Please refer to the attached JD
Person specification
Experience
Essential criteria
19. Previous experiences in working QSI projects and Quality Management system.
20. Leading service changes to improve performance
21. Identifying and interpreting national policy and implementing required changes
Qualifications
Essential criteria
22. Management/leadership qualification or equivalent experience at Masters Level
23. Evidence of audit/UCAS assessment process
24. Evidence of continued professional development
25. Further relevant specialist training
Desirable criteria
26. Project Management Qualification
Knowledge
Essential criteria
27. Business planning /annual planning/long term planning
28. Operational service management
29. Excellent understanding of the current NHS agenda and healthcare policy
30. Risk management and governance
Personal skills
Essential criteria
31. Ability to embrace, lead and drive change
Experience
Essential criteria
32. Proven experience of working in a management/leadership role Experience of managing, leading and motivating a team
Desirable criteria
33. Experience of working in an NHS acute hospital
Applicant requirements
You must have appropriate UK professional registration.
This post is subject to the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (Amendment) (England and Wales) Order 2020 and it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service.