JOB DESCRIPTION Quality Assurance Administrator Quality Assurance Manager Director of Care and Operational Services Job Title Reporting To Accountable To Role Summary • The postholder will have excellent proven general administration skills to support the Quality Assurance and Clinical Governance requirements of the Hospice. To assist in the development and monitoring of policies, procedures, guidelines, systems and infrastructure, which will ensure Halton Haven Hospice meets with its statutory, regulatory, and other compliance requirements in respect to the Care Quality Commission (CQC) and Cheshire and Merseyside Integrated Care Board (ICB). • The Quality Assurance Administrator will assist in collating and analysing data from various sources into meaningful reports ready for presentation at both internal and external meetings as appropriate. • The post holder will be expected to liaise between health and social care professionals with some direct communication and support to patients and families. A flexible approach to working is required. Key Tasks Quality Assurance • Responsible for collating data required to inform monthly quality reporting. This involves liaising with key personnel across several departments to ensure the data is received in good time in order to input and publish reports to schedule. • Maintenance of up-to-date patient data appropriate to facilitate external and internal reporting QA ADMINISRATOR JOB DESCRIPTION – 24th JULY 2025 1 • Assisting in the production of quality and governance reports following receipt of necessary data and sharing the report with all appropriate stakeholders. • Support the Quality Assurance Manager in responding to information requests in a timely manner and within requested timescales. • Assisting with audit processes throughout the Hospice. • Promoting infection control and assisting in appropriate campaigns. • Assisting with the Hospice Clinical Governance/Patient Safety Meetings e.g. setting up a meeting schedule, setting an agenda for the meeting, producing minutes of the meeting. • Assisting with the preparation of a Quality Assurance Report for the Clinical Governance meeting. • Attendance at appropriate meetings, such as Clinical Governance Meetings. • Use of IT skills to demonstrate and evidence quality data. • Assisting with the maintenance of the Hospice risk register. • Assist in incident reporting processes, supporting the investigation of incidents as required. • Assisting with appropriate incident reporting to external stakeholders in a robust and timely manner. • Liaise with external colleagues as required to feed into locality data collection. • Participation in patient and carer feedback processes, including working with the Hospice Patient and Carer Representative. • Support Halton Haven Hospice to meet all regulatory, mandatory and statuary requirements, such as Care Quality Commission regulations and contractual service specifications. • Ensuring that the Hospice is familiar with the latest requirements from CQC in terms of evidencing Quality Statements and inspection processes. Assessing how the Hospice meets the Quality Statements and having the assessment of evidence of compliance available. Also ensuring that any gaps in evidence have action plans. • Assisting with the production of the Hospice annual Quality Account, ensuring that it is produced on time for presentation to stakeholders and then having the final version ready for publication at the end of June. • Assisting with Policy Reviews to a set schedule, ensuring that each Hospice Department reviews existing policies or produces new policies as required. • Maintain professional development in line with amendments to Quality Assurance specific requirements Policies and Procedures • Understand and comply with the policies and practices of Halton Haven Hospice. QA ADMINISRATOR JOB DESCRIPTION – 24th JULY 2025 2 • Undertaking of policy development and review in line with set schedule of work • Attend statutory training in accordance with Halton Haven Hospice requirements. Health and Safety • The post holder must familiarise themselves with matters relating to health and safety management as they affect them personally and/or Halton Haven Hospice reporting any potential risks to life or property immediately in accordance with the Halton Haven Hospice Health & Safety policy and procedures. Staff must use all equipment provided to undertake their role safely. Other • Maintain absolute confidentiality in all areas of work. • Always behave with complete integrity, respect and professional dignity ensuring actions enhance the reputation of themselves and charity. • Any other duties commensurate with the grade and post. Safeguarding • is the responsibility of It the implementation of the Safeguarding policies, supported operationally by the Executive Management Team. the Hospice Trustees to oversee • While the Hospice Safeguarding Lead has primary legal responsibility for safeguarding at the Hospice, it is the everyday responsibility of each member of staff to actively safeguard our patients, service users and their families. • All staff, volunteers and trustees working for, or on behalf of, Halton Haven Hospice have a duty to not only promote the welfare and safety of adults at risk but to also report incidents of potential or actual harm. • Safeguarding Adults training, Safeguarding Children training, and Prevent Awareness training and Mental Capacity training are mandatory for all staff members. • The Hospice’s recruitment policies and procedures include legislative checks to ensure candidates are suitable for appointment. The Hospice shall recruit in line with this policy and procedure to protect those in its care as far as is reasonably practicable. Equality and Inclusion • Promote a culture which respects and values diversity, and support patients, visitors, and staff in exercising their rights. Foster an environment QA ADMINISRATOR JOB DESCRIPTION – 24th JULY 2025 3 and service which strives to reflect the diversity of individual needs within the Hospice. • Promote and demonstrate awareness of anti-discriminatory practice or behavior which undermines equality and diversity in accordance with organisational policies and current legislation. • Ensuring compliance and assisting in producing reports for stakeholders in respect to the Hospice’s compliance with Equality and Inclusion criteria. NOTE: The duties and responsibilities referred to are an outline only and may be changed in conjunction with the post holder, and in accordance with the needs of the Hospice. Any offer of employment will be conditional and subject to pre-employment checks as deemed appropriate to the role including identity, DBS, qualification, right-to- work, reference checks etc. QA ADMINISRATOR JOB DESCRIPTION – 24th JULY 2025 4