Job Description

JOB PURPOSE The post holder is responsible for supporting the Head of Nursing and CSU Clinical Quality Matron to facilitate the ongoing accreditation and development of the quality systems within Trauma and Related Services, working with Medical, Nursing, Management and Heads of support services. The post holder will assist the Head of Nursing and the Clinical Quality Matron in the development and maintenance of a quality programme across all specialities within the CSU. The post holder will co-ordinate multi-speciality meetings, activities with other professions and agencies. The post holder will be able to initiate the planning and coordination of these activities.



The post holder will be able to manage a number of these complex activities at any time on a daily basis. The post holder will attend meetings and provide administrative support to clinical colleagues as required, for example during Peer Review. The post holder will also be involved in the development and maintenance of audit schedules, service improvements and root cause analysis where needed within the CSU. Quality system(s) and/or projects will be allocated to the post holder who will be responsible for ensuring day to day management and updating of the quality systems.



The post holder will be expected to attain basic knowledge of all areas and discuss and highlight incidents as they occur. The post holder will collate information for the Head of Nursing and Clinical Quality Matron. The post holder will set agendas, attend meetings, take minutes and liaise with staff to ensure that actions are completed The Post holder will create and maintain action trackers for all patient safety incidents including outcomes of meetings and following up actions. The post holder will collate the formal complaints for the CSU and ensure accurate and up to date records and tracking logs are maintained as well as assisting the managers with completing responses.



The post holder will support the CSU education program, booking rooms, updating calendars and spread sheets and preparing materials for study days and quality. The post holder will collate the PALs complaints for the CSU and ensure accurate and up to date records and tracking logs are maintained as well as assisting the managers with completing responses. The post holder will track all investigations via a dashboard and upload action logs to datix. The post holder will support the administrative team within the CSU with additional duties as required and following discussion with their line manager, such as triumvirate PA holiday cover, to ensure service delivery.



The post holder will be based at the Leeds General Infirmary (LGI) but may be required to travel and work across other hospital sites within the Trust. JOB DIMENSIONS The post holder will work with Medical, Nursing, Management and other colleagues within and outside the CSU, to support the senior team in the development, implementation and maintenance of the current quality systems and in moving towards quality systems for all services within Neurosciences and will be required to liaise with other internal Trust departments and external Healthcare providers. The post holder will be jointly responsible for the issue and document control of all policies/procedures within their area and also ensuring review dates are notified to the Head of Nursing and CSU Clinical Quality Matron and added to the agenda of the appropriate review meeting. The post holder will support the Head of Nursing and CSU Clinical Quality Matron in ensuring continuous improvement across all aspects of the Directorate through audit, patient questionnaires and service improvement initiatives.



The post holder will support CSU and speciality Triumvirate teams with collating and gathering information on a regular basis as well as preparing presentations for specialty and CSU governance meetings and other meetings, such as HCAI. PRINCIPAL DUTIES & AREAS OF RESPONSIBILITY KEY RESPONSIBILITIES Assists in the delivery of the service by providing relevant data for presentation at local meetings as required. Assists the Senior Triumvirate team in providing relevant information to support to all staff as required. .



Assist the Head of Nursing and Clinical Quality Matron in the day to day delivery of the quality service within the CSU. Keep accurate records for data, analytical and auditing purposes as required and requested by Nursing, Medical and Management teams and in line with local and Trust policies and procedures. Ensures accurate record keeping and tracking of complaints as well as maintaining a spreadsheet for themes and outcomes and the recording of action plans. Ensures accurate record keeping and tracking of patient safety incidents including HCAI, pressure ulcers and falls with harm within the CSU as well as the upkeep of action plans and maintaining spreadsheets and trackers, providing information to support the Matrons and Head of Nursing as required.



Ensures accurate records for incidents and investigations for data and presentation purposes. Works with the relevant specialty Governance leads to monitor the progress of the Annual Clinical Audit programme and any agreed action plans and ensure the target level of performance is achieved for audits. Works with the relevant matrons and clinical leads to ensure progress of the annual Nursing and medical audit programmes and any agreed action plans and to ensure the target level of performance is achieved for audits. To work with relevant specialty Governance leads and clinical leads to coordinate CSU and specialty governance including agenda setting, minute taking and tracking actions.



Ensures the collection of up to date evidence for assurance of the annual self-assessment audit. Ensures that the root cause analysis meetings are arranged and reporting requirements are completed on time. Analysis and Data Management To produce routine performance reports to measure key indicators of service delivery. Personal Development To keep up to date on legislation relevant to Clinical Governance.



To participate in the Trusts appraisal processes and have in place a Personal Development plan. The post holder must take responsibility in agreement with his/her line manager for his/her own personal development by ensuring that continuous professional development remains a priority. The post holder will undertake all mandatory training required for the role.