Job Description Quality and Patient Safety Administrator Responsible to Director of Quality and Operations Hours 30 hours/ week Job Purpose • To support the delivery of the quality and patient safety function within the Hospice by. • Providing support to clinical staff to enable audit completion, action plan monitoring and progression and identification of learning • Supporting with administration of the Vantage system process • Working with the clinical team to support investigation and coordination of learning responses to incidents or concerns/complaints in line with PSIRF processes • Support the collection and learning from feedback from patients/public • Working with the MDT to ensure feedback to the wider team for learning • Supporting the Registered Manager with submission of notifications to CQC via the portal • Assist in quality improvement projects as they arise, supporting with process and documentation • Support the ongoing work to maintain compliance with CQC standards Values The post holder will hold and engage with our organisational values; Together Excellence Actively Engaged Meaningful Compassion Accountability Respect Empathy Further information on our values and expected behaviours are listed at the back of this document Main Duties and Responsibilities • Work with service leads to support the implementation and embedding of patient/service user feedback processes. • Assist with the review of feedback data to identify themes for learning and sharing • Working with the Registered Manager and departmental leads to ensure that there is up to date evidence in place ensuring compliance with the Care Quality Commission Standards • Support team leads to investigate incidents, complaints and concerns, working with the relevant members of the clinical team ensuring complete documentation in Vantage • Support the use of the patient safety incident response framework (PSIRF) methodologies and other information available from patient safety and experience issues, in order to understand and share lessons learned. • Support the collation of relevant quality reporting, ensuring deadlines are met as per reporting schedules. • Responsible for supporting programmes of audit across all Oakhaven settings and co-ordinate the audit program. • Responsible for developing and supporting staff with oversight of action plans, coordinating actions where required, • Work with clinical colleagues and the Head of Marketing, to • ensure that patient information is accessible, up to date and of good quality • Ensure the timely management of policies and standard operating procedure documents, supporting with document management/ version control and publishing to the intranet • Proactively monitor for patient safety alerts /CAS alerts through the national CAS website and Vantage General Public Relations – To represent Oakhaven Hospice in the community and public domain as appropriate Personal Development – to keep up to date on current developments appropriate to duties and responsibilities of the post. To identify personal development needs with agreement of line manager. Training - To remain appropriately trained for the role and keep up to date with mandatory training requirements. Data Protection – To be conversant with the requirements of the Data Protection Act and ensure compliance in safeguarding confidential information. Health and Safety – To be aware of and comply with current Fire, Health and Safety Policies and Procedures operated at Oakhaven Hospice. Ensure risk assessments are conducted for each event and appropriate insurance cover obtained. Confidentiality – To be aware of the confidential nature of hospice affairs and comply accordingly. Finance – To act with a sense of integrity and sound judgment and to take personal responsibility for understanding and following all relevant financial policies. Additional Duties – In discussion with line manager to undertake work as and when required in support of Oakhaven Hospice. OAKHAVEN HOSPICE Notes • The post-holder may have access to confidential data on staff, patients and services within the hospice. Failure to maintain confidentiality will lead to disciplinary action, which could ultimately lead to dismissal. • The post-holder may be required to contribute towards clinical and corporate governance agenda as appropriate. • The post-holder will be the subject of regular annual appraisal and objectives. • The post-holder will be expected to produce work to a high standard and to promote quality at all times. • The Hospice is committed to Equal Opportunities for all current and potential members of staff and patients, irrespective of gender (including gender re-assignment), marital status, sexual orientation, race, colour, creed, religion, belief, nationality, ethnic origin, age, disability, a positive diagnosis of HIV/AIDS, or Trade Union membership. Therefore, the Hospice expects of its staff to understand, support and apply this policy through their working practices, which requires all individuals to be treated with respect, dignity, courtesy, fairness and consideration. • The post-holder will be expected to keep themselves updated on all matters relating to Hospice Policies and Procedures. • The post-holder must familiarise themselves with matters relating to health and safety management, reporting any potential risks immediately in accordance with the Hospice’s Health and Safety policy and procedures. • The employee will also be expected in discussion with their manager, to understand their role and level of accountability in respect of Emergency Planning procedures and ensuring controls assurance within their work area. • This is an outline job description and may be subject to change, according to the needs of the service, in consultation with the post holder. • Oakhaven Hospice is a non-smoking building and this is to be observed at all times. The ‘Why’ of Oakhaven PERSONAL VALUES Making every moment matter We do what we do at Oakhaven Hospice because as individual people we hold the personal values of Compassion, Accountability, Respect and Empathy in high regard. In other words we CARE about what we do and the people we work with. Compassion We show compassion when we act with understanding and work cooperatively with others. We treat each individual as unique, valuing them without distinction or judgement Accountability Respect Empathy We continually learn from our experiences and use this understanding to develop services and maintain excellence as standard. We treat and communicate with our team members, patients and community with mutual respect, recognising the importance of their contribution We demonstrate awareness of an individual's situation from their perspective and respond compassionately in an understanding manner. We take responsibility for our decisions and actions, alongside creating a culture of no blame. We value the diversity of others in both opinion and culture and do not dismiss what we do not understand or agree with. We listen and help people based on their individual needs and feelings. The ‘Why’ of Oakhaven ORGANISATIONAL VALUES Making every moment matter As an organisation we strive to ensure our service is one that: works Together with others; delivers Excellence and is based on best practices and principles; is Actively engaged on all levels be it with patients, families, the local community, staff and services both internal and external; is Meaningful for those who experience it. We strive to work within and as part of a TEAM. Together We work as one team across We make the best use of Oakhaven and share our knowledge, skills and experience with others to deliver excellence. resources by accessing knowledge and skills from partners to support Oakhaven in delivering excellent service. Excellence Actively engaged Meaningful We strive for a professional, high quality service which is responsive to need and works to ethical, sound and best practice principles. We demonstrate a belief in the ethos and principles of Oakhaven and are supportive of the day to day operation at all levels, individual, team and organisational. We are aware of the value and impact Oakhaven can have on individuals, teams, organisation and the community. We reflect and act on constructive feedback from others in order to learn. We respond positively to new ideas and approaches and propose solutions when faced with problems. We understand how our response and actions can affect a person’s experience. Personal specification Requirement Essential Desirable Education, Training and Qualifications 5 GCSEs or equivalent including mathematics and English. Skills and Knowledge Excellent communication skills Experience of using Microsoft Teams and the Microsoft suite including Excel, Power Point, SharePoint and 365 Strong organisational skills, time management, ability to prioritise workload independently Strong attention to detail and ability to produce information to a high quality Previous administration experience in a healthcare environment Experience of an electronic incident reporting platform such as Datix, Vantage or Ulysses. Knowledge of the CQC Standards Knowledge of principles of PSIRF Experience Experience of administrative roles and working within processes/ standards Experience in clinical audit. Personal Attributes Able to demonstrate behaviours consistent with Trust Core Values. High regard for the work of hospices with the commitment to their ethos Proactive, ‘can do ‘and flexible attitude Able to work with minimal supervision, using initiative and seeking guidance when necessary Confident in liaising with a range of people Ability to meet deadlines. Willingness to learn and develop.