Overview
JOB DESCRIPTION JOB TITLE: Quality Assurance Manager
REPORTS TO: Quality Improvement Lead
REPORTED TO BY: N/A
MAIN RESPONSIBILITIES: Maintain and develop the Hospice's compliance with care standards and all other relevant regulation and best practice guidance throughout its clinical and general operations. The format and review of clinical and non-clinical policies to ensure compliance with relevant legislation. To coordinate a holistic clinical and non-clinical audit process, including strategic standard setting, efficient measurement systems, robust feedback and the facilitation of action plans. Act as Health and Safety Lead for the Hospice ensuring compliance with relevant Health and Safety legislation. To provide quality assurance services to Rossendale Hospice as outlined in the service level agreement. Senior Information Risk Officer (SIRO).
Responsibilities
* Clinical: Ensure the Hospice delivers care in an effective, safe, responsive and well-led manner in conjunction with the Clinical Services Manager and Clinical Departmental Managers. Work with relevant colleagues to develop new and review Hospice policies and procedures as required. Maintain up-to-date knowledge of all relevant Care Quality Commission standards and ensure these are reflected in Hospice practice and compliance activities.
* Management and Leadership: Work closely with the Hospice senior management team (SMT) and all relevant professionals to ensure that staff and volunteers deliver high levels of service and care at all times. Contribute to and lead the ongoing development of operational policies, procedures and clinical guidelines, ensuring their implementation, review and monitoring. Be an inspirational leader who clearly expresses the hospice vision, values and service quality to team members at all times. Set high standards of quality and performance and raise the level of expectations. Accept accountability for own actions and areas of responsibility. Compile and present relevant reports to senior managers and Hospice committees as required (e.g., Audit, Health & Safety, Service user experience). Involve others in decision making and empower where possible. Provide out-of-hours management on-call cover.
* Communication Skills: Foster good working relationships and effectively communicate with members of the multidisciplinary team, users of the service and other professionals working externally. Work in accordance with Hospice policies to ensure that confidentiality is maintained at all times.
* Personal and People Development: Accept responsibility to maintain and update the skills required to fulfill the job role. Share knowledge and experience with other staff to improve patient care. Encourage other staff to share good practice and knowledge. Ensure that revalidation requirements (e.g., NMC, HPC registration) are fulfilled.
* Quality and Service Improvement: Formulate and execute the Hospice's audit schedule, ensuring that all relevant practice and activity is subject to verification against documented policy and procedures. Ensure that any actions identified as part of the audit process are implemented effectively. Identify areas for quality improvement and work with the Quality Improvement Lead and relevant staff to implement effectively. Train and develop staff in clinical and general audit relevant to their job role, focusing on a team approach and encouraging ownership of compliance issues throughout the organisation. Coordinate the reporting of adverse incidents, accidents, near misses, and errors, ensuring that a log of all incidents is maintained and any actions identified implemented effectively. Oversee, and contribute as necessary, to the investigation of incident, accident and near-miss reports. Develop and maintain a communications strategy for cascading relevant safety information (e.g., CAS alerts, RIDDOR, ICO, etc.).
* Health, Safety and Security: Lead the Hospice's health and safety function (including fire safety) across the organisation. Ensure that the Hospice is able to demonstrate compliance with all relevant Health and Safety requirements with particular emphasis on documentation and maintenance of necessary risk assessments. Ensure the completion of all risk assessments and implementation of appropriate actions as necessary. Ensure new risks identified are added to the organisational risk register and followed up. Train and develop staff in health and safety relevant to their job role, focusing on a team approach and encouraging ownership of compliance issues throughout the organisation. Assist the Clinical Services Manager with the coordination of the Hospice Prevention and Control of Infection Group and development of a strategy that promotes and monitors excellent practice in relation to the prevention of infection.
* Governance: Assist the Registered Manager in ensuring that the Hospice meets all necessary Care Quality Commission (CQC) Standards. Ensure that Hospice policies and procedures are compliant with relevant legislation and best practice guidance, documented and communicated effectively. Ensure that Hospice policy and procedural documents are organised and maintained in a controlled manner. Plan and execute a rolling plan for the timely review and amendment of all relevant policy and procedural documents. Support the Hospice senior management team in ensuring that the Hospice is compliant with all legislative and governance frameworks relating to use of computer systems including compliance with the NHS Information Governance Framework. Complete the annual NHS Information Governance Toolkit in a timely manner. Ensure that the Hospice is compliant with the General Data Protection Regulation (GDPR). Ensure that Hospice policies, procedures and standards are adhered to at all times with particular regard to those concerning confidentiality, information governance, health and safety, prevention and control of infection and medicines management. Ensure effective outcome monitoring of service delivery.
Note: This document is intended to convey an outline of the post and the post-holder's responsibilities. You may be asked to carry out other duties relevant to your job role.
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