Compliance Analyst

About Us

EPUT provides community health, mental health and learning disability services to support more than 3.2 million people living across Bedfordshire, Essex and Suffolk. Also:

• We are among the largest employers in the in the East of England region, with more than 10,000 staff working across more than 200 sites.
• We run the COVID-19 vaccination programme across mid and south Essex and Suffolk and north east Essex.

EPUT was formed on 1 April 2017 following the merger of North Essex Partnership University NHS Foundation Trust (NEP) and South Essex Partnership University NHS Foundation Trust (SEPT). A new leadership team was established at the Trust in 2020.
Our vision and values

Our Vision

"To be the leading health and wellbeing service in the provision of mental health and community care".

Our Purpose

"We care for people every day. What we do together, matters".

Our Values

• We Care
• We Learn
• We Empower

Our strategic objectives

• We will deliver safe, high quality integrated care services.
• We will enable each other to be the best that we can.
• We will work together with our partners to make our services better.
• We will help our communities to thrive.

Our services

• Mental Health Services
• Community Health Services
• Learning Disabilities Services
• Social Care

Find out more about the services we offer in our service directory.

Job overview

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.

Main duties of the job

• 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,

Working for our organisation

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.

Detailed job description and main responsibilities

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

Communication and 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.

Person specification

Statement and Qualifications

Essential criteria

• Educated to degree level or demonstrable equivalent experience
• Detailed knowledge and experience of DoH fundamental standards and CQC Key Lines of Enquiry (KLOEs)/Quality Statements
• Detailed knowledge of the CQC Registration requirements/standards
• Detailed knowledge and experience of policy/procedure development
• A broad knowledge of the supporting agendas and frameworks that impact on service delivery such as Clinical Governance, HR, Workforce Development etc. and an in depth understanding of how these may impact on planning, performance and assurance systems within the trust.
• Experience of maintaining electronic databases and working with electronic information systems
• Ability to communicate complex, conflicting and sensitive information at all levels in the trust
• Excellent written & verbal skills
• Ability to prioritise own and other's workload demands in pressured situations
• Ability to analyse conflicting information
• Ability to undertake auditing, monitoring and investigation
• Ability to make judgements about information involving complex facts received and action on this appropriately
• Ability to develop detailed plans and strategies (operational framework) at an strategic organisation wide level - both short term and long term
• Ability to develop trust wide policies and procedures in line with best practice
• Experience of information system development
• Ability to act on own discretion and take action based on own interpretation.
• Team worker
• Assertive
• Motivated
• Flexible approach to working patterns
• Able to use own initiative
• Ability to travel

Statement and Qualifications

Desirable criteria

• Experience of working at a senior level in an NHS environment
• Clinical experience

Please note - staff who are formally at risk within the organisation will be given priority in securing alternative employment. Should it come to light that a post being advertised by the Trust is considered 'suitable alternative employment' to an individual who is at risk, the recruiting manager will be advised and the post will be withdrawn from NHS Jobs.

Important Professional References

Make sure that as a part of your application you have professional references with business contract information covering your last three year employment history. We are unable to accept personal or character references.

As a newly appointed employee you are responsible for incurring the cost of your initial DBS check relevant to your post, the amount will be deducted from your first salary with the Trust.

Applications for Job Share are positively welcomed.

Equal Opportunities Employer

Our Trust is an Equal Opportunities Employer. We particularly welcome applications from people with experience of using mental health services. We also hold the Disability two tick symbol and have made the pledge to commit to employing more people with learning disabilities, we encourage people with a disability to apply. If you require this application form in another format i.e. Braille or audio tape etc, please contact the Recruitment Department on 01375 364513 or email epunft.recruitment.adverts@nhs.net and we can arrange for this to be dispatched to you.

The Trust has the right to expire vacancies prior to the closing date if they so wish. The Trust makes every attempt to contact all applicants and we strongly advise that you check the email account which is registered with NHS Jobs regularly, we would advise however due to the high number of applications we receive that if you have not heard from us within three weeks of the closing date your application has been unsuccessful on this occasion.

We are committed to safeguarding and promoting the welfare of children, young people and vulnerable adults, and expect all staff to undertake this commitment. Applicants will be subject to robust safer recruitment processes.

Covid Vaccination

Although Covid vaccinations are no longer a mandatory requirement within the NHS we continue to encourage and support the vaccination uptake as this remains the best line of defence against Covid19. The safety of our staff and patients is a top priority for us at EPUT.

If you would like to book a Covid vaccination or would like more information please contact us by emailing epunft.cv19hr@nhs.net.

Employer certification / accreditation badges

Documents to download

• Job Description (PDF, 744.3KB)
• Person Specification (PDF, 528.3KB)
• Why Join The NHS Pension Scheme (PDF, 91.3KB)
• EPUT Pledge - Step into Health (PDF, 211.0KB)
• Candidate Privacy Policy (PDF, 336.6KB)
• Right to Work Information (PDF, 293.6KB)
• Employer Recognition Scheme - Gold Award (PDF, 27.7KB)
• Trust Vision and Values (PDF, 168.9KB)
• Values of the NHS Pension (PDF, 151.3KB)
• EPUT Staff Benefits (PDF, 89.3KB)