Job description

Job responsibilities

Quality assurance and inspection readiness

Keep a live self-assessment of every site against CQCs five key questions, using whichever assessment framework CQC has in force, with the evidence held in one place and every gap owned and tracked to closure.

Run an annual audit programme including on clinical protocols/processes, infection prevention and control, cleanliness, cold chain, and emergency medicines and equipment and make sure every finding becomes an action with an owner and a date.

Close the loop: report audit results back to the teams and sites that produced them, and check that agreed changes have actually happened.

Report regularly to the Quality and Safety Group on what has been checked, what was found, what has been done and what is still outstanding.

Review incidents, significant events, complaints and patient feedback for themes, and turn them into learning events and changes in practice. Individual cases are handled through the established processes; this post

looks across them. Where a theme or case involves nursing practice, agree the clinical learning with the Lead Nurse, then take it back to the nursing team through team meetings, clinical supervision or learning events in a way that encourages reflection rather than blame.

Where an individual nurse is involved, hold the feedback conversation jointly with the Lead Nurse the manager covering process and conduct, the Lead Nurse covering clinical practice and help the nurse record it as reflective evidence for revalidation.

Keep the clinical and quality risks on the organisations risk register current, with named owners and mitigations.

Keep nursing and clinical-quality policies and procedures current within the organisations policy register, with clinical sign-off from the Lead Nurse, and make sure staff know what has changed.

Safe care systems

Vaccines and cold chain: own the standard and the system at every site fridge monitoring and records, transport between sites, stock checks, and escalation and reporting of any breach. The Planned Care Manager runs vaccination campaigns and ordering; the Lead Nurse makes the clinical decision on any breach.

Infection prevention and control: run the programme across all sites audits, training compliance and action plans with the Lead Nurse as named IPC lead.

Cleanliness and clinical waste: audit sites against the national cleanliness standards and waste requirements, and report contractor performance to the Operations Manager, who holds the contracts. Patient Services Managers manage day-to-day arrangements on site.

Routine safety checks: make sure checks on emergency medicines and equipment, medical device servicing and calibration, and sharps happen, are recorded and are acted on.

Patient Group and Patient Specific Directions: keep the register of who is authorised to work under each one, with renewal dates, so nobody works under a lapsed authorisation.

Leading the nursing team

Line manage the nursing team registered nurses, nursing associates and healthcare assistants, around 40 staff across eight sites directly and through a support layer : induction, probation and objectives, one-to-ones, appraisal, absence and return to work, conduct and capability, working with HR.

Make sure every member of the team has an annual appraisal with objectives and a development plan. For NMC registrants, support nurses to complete where appropriate, once they have had their reflective discussion with another registrant.

Work with HR to keep one record of every team members registration and revalidation dates, mandatory training and competencies; flag expiries early; and make sure nobody is rostered for work they are not signed off to do.

Agree with the Nurse Lead a single joint process for concerns about an individual, so that issues involving both conduct and clinical practice are dealt with once, together, rather than passed between the two.

Plan nursing capacity and skill mix across sites against demand working with the Planned Care Manager including long-term condition recalls, vaccination campaigns and extended opening hours and manage rotas, cover, and bank and agency use.

Lead recruitment to nursing posts with HR, with the Lead Nurse on interview panels to assess clinical skills.

Make sure nursing has a voice in operational decisions that affect clinical practice, bringing in the Lead Nurse where clinical input is needed.

Build a team culture in which people report problems and mistakes because they know the response will be learning, not blame.

First-year priorities

By three months: one current record of every team members registration, revalidation date, training and competencies; an appraisal schedule covering the whole team; and a baseline infection prevention and cold chain audit at every site.

By six months: a baseline self-assessment of every site against CQCs key questions, with a gap-closure plan agreed by the Quality and Safety Group; a regular assurance report in place; and the first themes report from learning events, patient feedback and complaints, with learning actions.

By twelve months: every team member appraised with objectives; the audit programme running to schedule with actions closed; nursing policies current; and an organisation that is consistently ready for inspection.

Special working conditions

The postholder will work across all Affinity Care sites, in person, and may occasionally be asked to be flexible in their working hours to meet the needs of the service.

This job description is not exhaustive and will be reviewed with the postholder as the role develops. The postholder will treat information as confidential in line with organisational policy, complete mandatory training including safeguarding at the level required, promote equality, diversity and inclusion, and take reasonable care for their own and others health and safety.

Person Specification

Personal Qualities

Essential

• Essential
• Credible with clinicians without being one
• Finishes what they start and closes loops
• Fair, consistent and collaborative; builds a learning rather than a blame culture
• Able to work flexible hours
• Able to work across all sites in person, with occasional flexibility in
• hours
• Must have evidence of required vaccinations to be considered for the
• post

Desirable

• Ability to communicate at Board level

Qualifications

Essential

• Educated to degree level, or equivalent management experience*
• Willingness to complete the training the role requires, including
• infection prevention and control lead training

Desirable

• Management qualification, e.g. ILM or CMI Level 5 or above
• Quality improvement or audit training

Skills and Knowledge

Essential

• Raises performance concerns directly, fairly and early, and follows
• them through
• Keeps many recurring compliance cycles running across several sites
• without relying on memory
• Writes clear, concise reports for a committee; confident with Excel and data
• Understands CQCs five key questions and what good evidence for
• each looks like in general practice

Desirable

• Working knowledge of NMC revalidation, infection prevention and
• control standards, vaccine storage guidance and the national
• cleanliness standards
• Experience of SystmOne, Practice Index or an audit platform such as
• MEG

Experience

Essential

• Line management of a team across more than one site, including
• appraisals, absence management and at least one performance or
• capability process taken through to conclusion
• Running an audit or assurance programme end to end audit, action
• plan, evidence of closure and reporting to a committee or board

Desirable

• Working in general practice or wider primary care
• Preparing evidence for, or taking part in, a CQC assessment in a health
• or care provider
• Managing registered clinical staff as a non-clinical manager
• Monitoring a contractors or suppliers performance against a standard

Disclosure and Barring Service Check

This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.

Employer details

Employer name

Affinity Care

Address

Affinity Care

Shipley Medical Practice

Alexandra Rd

Shipley

West Yorkshire

BD18 3EG

United Kingdom

Employer's website

https://shipleymedicalpractice.nhs.uk/ (Opens in a new tab)