The Compliance and Quality Improvement Officer will support the delivery of the Trust’s compliance and quality improvement programme, ensuring alignment with Care Quality Commission (CQC) standards and internal governance processes.
Working closely with the Compliance and Quality Improvement Manager, the post holder will coordinate compliance activities, support audits, facilitate inspection readiness, and contribute to quality improvement initiatives across clinical and corporate services.
The role is key in maintaining oversight of compliance evidence, supporting services with action tracking, and promoting a culture of continuous improvement.
We have an excellent reputation for being innovative, responsive and flexible to the changing clinical needs of the local population. We are treating more patients than ever before and are dedicated to improving services to deliver the best for our patients.
Our mission
Helping local people live longer, healthier lives.
Our vision
Provide safe, personal, co-ordinated care for the community we serve.
Our goals
We have developed six key strategic goals to make sure we continue to support people to live longer, healthier lives.
- To secure the best possible health and wellbeing for all our community
- To integrate and coordinate care in person-centred teams
- To deliver consistent, high quality, safe services
- To support our patients and users in being active partners in their care
- To be recognised as a leader in the fields of medical and multi-professional education, and population-based clinical research
- To innovate and continuously improve the quality of our services to deliver the best outcomes for our local population
Regulatory Compliance and Governance
- Support the implementation and monitoring of the Trust’s compliance framework.
- Assist in coordinating CQC preparation activity, including evidence collation and gap analysis.
- Maintain compliance trackers, dashboards, and documentation repositories.
- Support the delivery of mock inspections, peer reviews, and self-assessments.
- Monitor action plans arising from inspections, audits, and reviews, ensuring timely completion.
- Assist in preparing reports and briefing papers for governance committees.
Working with Nursing and Ward Teams (CQC Readiness and Peer Review)
- Work collaboratively with ward leaders, matrons, and nursing teams to support operational readiness for CQC inspections.
- Provide hands-on support to clinical areas to ensure compliance with CQC and fundamental standards.
- Lead in the planning and delivery of mock CQC inspections (peer reviews) across inpatient and community services.
- Lead peer review visits, including evidence review, staff and patient engagement, and observational assessment of care delivery.
- Support wards to identify gaps in compliance and develop clear, actionable improvement plans.
- Monitor and follow up on actions arising from peer reviews to ensure sustained improvement.
- Work with nursing teams to improve visibility and accessibility of compliance evidence (e.g. safety huddles, boards, documentation).
- Support the development of ward-level understanding of “what good looks like” for CQC inspections, including coaching staff where required.
- Promote a culture of continuous learning and quality improvement within frontline teams.
- Provide feedback and escalation to the Compliance Manager on themes, risks, and areas of good practice identified through ward engagement and peer review activity.
- Escalate issues appropriately in line with organisational processes.
Audit
- Coordinate audit programmes and compliance monitoring via the Trust audit system.
- Coordinate the development of the ward accreditation programme.
- Collect, analyse, and interpret data from audits and peer reviews.
- Contribute to reporting for governance committees.
Policy and Process Support
- Maintain systems for tracking policy reviews and updates.
- Coordinate services in ensuring policies align with national guidance and regulatory standards.
- Assist in quality assurance of governance documentation.
Inspection Readiness and Engagement
- Support preparation for external inspections (e.g. CQC), including logistics and communications.
- Supporting the development of materials such as evidence packs, presentations, and briefings.
- Work with clinical and operational teams to ensure inspection readiness at service level.
Communication and Collaboration
- Act as a key point of contact for compliance queries from services.
- Build effective working relationships across divisions and governance teams.
- Develop the delivery of training and awareness on compliance and governance processes.
- Promote a culture of openness, learning, and continuous improvement.
Data, Reporting and Systems
- Maintain and update compliance dashboards and reporting tools.
- Support data collection and analysis for governance reporting.
- Contribute to the production of reports for committees including Quality Committee.
General Responsibilities
- Act in accordance with Trust values, policies, and professional standards.
- Maintain confidentiality and comply with data protection requirements.
- Be flexible in working patterns to meet service needs.
Key Relationships
- Executive Directors and Divisional Leadership Teams
- Quality Committee, Audit and Risk Committee, and Patient Safety Committee
- Head of Quality Governance and Risk Governance Manager
- Chief Medical Officer, Chief Operating Officer, and Nursing Leadership Team
- IM&T, Business, and Performance Teams
- External Regulators (e.g., CQC, NHS England)
- Partner Agencies and Stakeholders
- Patients and service users
