Compliance Analyst | Essex Partnership University NHS Foundation Trust

The post holder will be responsible for ensuring the Trust compliance framework is maintained and keeping a comprehensive database of CQC related intelligence that is active and analysed for compliance assurance. The postholder will be responsible for ensuring that all locations can demonstrate their compliance with the CQC Registration requirements. The post holder will be required to provide cross cover with the teams Compliance Assistant(s) and cover other Trust services as directed by the Head of Compliance and Emergency Planning.

• Responsible for raising awareness about the CQC Registration Requirements across all areas of the Trust
• Responsible for the development of a system for the analysis of intelligence against the CQC registration requirements.
• Responsible for supporting the identification and analysis of information intelligence sources which provide assurance of compliance or indications of risk of non-compliance with CQC Registration requirements.
• Responsible for facilitating in the development and collection of evidence for external Trust inspections including DOH inspections, peer reviews and CQC inspections.
• Will participate in comprehensive inspections of compliance and will be responsible for monitoring outcomes against any inspection criteria and ensuring that information is fed back to improve service delivery and that any changes are implemented to meet the agreed timescales.
• The post holder will be responsible for ensuring that robust evidence is available for external inspections in the appropriate electronic format (where possible).
• Responsible for supporting and facilitating internal comprehensive inspections of Trust services and teams against CQC registration requirements.
• Responsible for assisting with the development and maintenance of the system that provides assurance to the Trust Board of Directors
• Responsible for designing appropriate monitoring methods and audit tools,
EPUT are looking for motivated staff who shares our Trust values of Care, Learn and Empower. In return, EPUT can offer you a range of benefits and development including;
• Season Ticket Loans
• NHS discounts for staff
• Excellent Training facilities and opportunities
• Buying and Selling annual leave scheme
• The opportunity to work bank shifts and expand knowledge and experience in other areas
• Salary Sacrifice schemes including lease cars and Cycle to Work
• Day One Flexible Employer
The Trust supports and actively encourages flexible working for all employees. We offer many options and you are encouraged to ask the recruiting manager what is possible for this role. If appointed, you will have the opportunity to apply for a flexible working request from the first day of your employment Join our Staff bank What is Staff Bank? Our EPUT NHS staff bank is an entity managed by the trust that hires clinical and non-clinical healthcare professionals to take on shifts at our trust hospitals and community settings. Here at EPUT we maintain our own bank of specialist staff to ensure that we are able offer safe and effective care at all times. All our permanent staff are automatically enrolled onto the staff bank however this does not mean you have to work any additional shifts, but the option is there for you if you wish. If you are joining our Trust in a fixed term role, please indicate on your New Starter Paperwork that you wish to join our staff bank. Operational Responsibilities
• Responsible for raising awareness about the CQC Registration Requirements across all areas of the Trust and will need a thorough understanding of national inspection criteria and links with CQC Registration Requirements, other national directives, litigation and claim implications.
• Responsible for the development of a system for the analysis of intelligence against the CQC registration requirements. The system will provide assurance of compliance and indications of potential non compliance.
• Responsible for supporting the identification and analysis of information intelligence sources which provide assurance of compliance or indications of risk of non-compliance with CQC Registration requirements.
• Responsible for ensuring policy documents meet the CQC registration requirements and the robust implementation and monitoring of all policy documents.
• Responsible for facilitating in the development and collection of evidence for external Trust inspections including DOH inspections, peer reviews and CQC inspections.
• Will participate in comprehensive inspections of compliance and will be responsible for monitoring outcomes against any inspection criteria and ensuring that information is fed back to improve service delivery and that any changes are implemented to meet the agreed timescales.
• The post holder will be responsible for assisting with the management of the external visits/inspection and accreditations system. This will include keeping a schedule of all expected visits/inspections and accreditations; keeping a record of all recommendations made at such visits; monitoring that action plans are completed; and that all committees of the Trust have been informed appropriately.
• The post holder will be responsible for ensuring that robust evidence is available for external inspections in the appropriate electronic format (where possible). This will involve negotiating with the key corporate and operational managers/clinicians on individual criteria and agree action plans to achieve required objectives. Meet with key personnel regularly monitor progress and ensure that any barriers to project delivery are addressed.
• Will prepare and co-ordinate all aspects of external assessment days in liaison with the Head of Compliance and Emergency Planning. This will include informing key personnel that they will need to be available on the assessment day to provide further evidence in person.
• Responsible for supporting and facilitating internal comprehensive inspections of Trust services and teams against CQC registration requirements. This will involve management of an annual calendar of inspections in partnership with operational and other support services, development of appropriate audit tools and review of intelligence held.
• Responsible for the coordination of Healthwatch and Director and Governor Quality visits.
• Responsible for ensuring that national best practice, legislative and CQC requirements are considered as part of all policy/procedure and strategy review.
• Responsible for assisting with the development and maintenance of the system that provides assurance to the Trust Board of Directors on the levels of compliance with Trust policies/ procedures and strategies across the trust.
• Responsible for designing appropriate monitoring methods and audit tools, where they do not already exist and reviewing existing methods and tools to ensure all policy/procedures and strategies are monitored effectively for compliance.
• Overview of Trust policies and procedures to ensure DoH fundamental standards and CQC key lines of enquiry (KLOEs)/Quality Statements are incorporated
Communicationand Working Relationships
• The role requires excellent communication skills both verbal and written, with the ability to develop collaborative working practices and relationships at all levels within the Trust. This will require the post holder to have well developed IT skills, particularly in the use of Microsoft Word, Excel and Power Point software programmes.
• The post holder will be responsible for supporting and sharing information intelligence at all appropriate levels of the Trust and providing intelligence for Trust Quality Summits.
• The post holder will report to the Head of Compliance and Emergency Planning; and Executive Team regarding performance against the external inspection requirements and highlight any barriers which may affect the project plan. This will include preparing written reports to appropriate committees.
• Responsible for supporting all services/locations across the Trust to maintain compliance with the CQC Registration Requirements. This will include facilitating each area to have a completed and up to date Local Portfolio of Evidence.
• The post holder will be responsible for supporting managers in the understanding and implementation of external inspections, including policy/procedure requirements and what constitutes appropriate evidence.
• The post holder, with support from the Head of Compliance and Emergency Planning, will ensure Senior Managers are aware of the relevance and importance of the standards to the Trust's strategic plan and for risk management. This will include ensuring that information is cascaded to staff at all levels by way of intranet, newsletters and Trust publications.
• The post holder will be responsible for undertaking/facilitating monitoring and auditing in partnership with Trust key leads of Trust policies/procedures and strategies where existing monitoring / auditing arrangements are not in place.
• The post holder will be responsible for proposing policy or service changes following audit/monitoring findings. This will involve participation on working parties proposing Trust wide policy changes in all areas of the Trust and all types of policy.
• The post holder will assist clinical leads with care planning developments in the Trust, including facilitation of trust documentation reviews.
• The post holder will support Emergency Planning, including logging decisions, as and when required.
Management
• The post holder will be responsible for attending appropriate Service Management Team meetings on behalf of the Compliance Team to present reports.
• The post holder will be responsible for attending appropriate committee meetings on behalf of the Compliance Team.
• Line management responsibility for staff including objective setting, conducting appraisals, monitoring training, compliance and day to day supervision.
Training & Development
• To undertake ongoing Personal and Professional Development in order to maintain own professional standards through attendance on training and education programmes commensurate with the duties of this post.
• To keep informed and up to date with developments in the areas of statutory and corporate requirements, technological developments and best practices in RMS and
• To ensure the consideration of patients and carers experience in all aspects of work.
Analysis and Judgement
• The post holder will have and will utilise: Highly developed analytical skills to understand and communicate complex information at all organisational levels.
• Clear and confident judgement making skills.
• Decisive decision making skills, informed by evidence.
• The ability to interpret national guidance into local policy and procedure.
Physical, Mental and Emotional Effort
• The post holder will be responsible for developing, maintaining and managing an IT based RMS compliance system. The post holder will be required to have good IT skills including excel, file management and outlook skills. The post holder will be required to have good keyboard skills and will be required to spend considerable amounts of time using the computer. The post holder will be required to input using a keyboard and to move service user case notes for the purpose of auditing.
• The post holder will be required to undertake frequent, prolonged and intent concentration in analysing complex information/data and while undertaking complex calculation and detailed analysis of statistics produced.
• The post holder will be required to work in all areas of the Trust (clinical and non-clinical) and will be required to work with clinical information such as service users case notes, incidents, SUIs, complaints and claims for the purpose of monitoring and reporting.
• The post holder will also be required to frequently travel to the different Trust sites to undertake audit and monitoring.