This document outlines the main duties and responsibilities of a role related to regulation, compliance, inspection, risk management, and documentation control. Key responsibilities include: 1) Participating in organizational preparation for external inspections and reviews, collating compliance evidence, and facilitating inspection visits. 2) Supporting the management of risks through activities like maintaining the risk register, providing risk management training, and managing the Central Alert System. 3) Maintaining governance systems, providing user support, and ensuring data quality and security. 4) Developing policies and standards, providing training, and facilitating work to ensure compliance with external assessments.

1. Main duties and responsibilities
Regulation, compliance and inspection
1) In conjunction with the Compliance Coordinator participate in organisational preparation
for inspection and review by the Care Quality Commission and other external agencies.
2) Collate, maintain and update contemporaneous evidence of compliance, identifying gaps
and producing updates in respect of the Trust’s position for the Head of Compliance, the
Compliance Manager, relevant committees and corporate and CAG teams, including
CAG and service line Governance Leads.
3) In conjunction with the Compliance Co-ordinator facilitate inspection visits by assessors
from external bodies, assembling documentation and post inspection and with the CAGs
creating and monitoring action plans as appropriate.
4) Maintain the CQC monitoring system outside of inspection periods to accurately reflect
the Trust’s current position at all times. Maintain robust audit trails that demonstrate the
management of evidence, closing actions including clear document version control.
5) In conjunction with the Compliance Coordinator identify and lead continuous and
sustainable improvement in relation to statutory compliance including any NHSLA
recommendations relating to reduction of clinical negligence claims, risks to the
organisation and by undertaking audit, benchmarking and evaluation of practice.
6) Ensure any risks to compliance are notified to the Compliance Coordinator and where
appropriate to Governance Leads within the CAGs and service lines.
Risk management, data handling and analysis
7) Support the Compliance Manager/Trust Risk Manager in the management of risks,
associated with the work of the Compliance Unit undertaking tasks and actions to
achieve objectives, including activities related to the development and maintenance of
the Nursing and Governance risk register.
8) Support the Compliance Manager and Trust Risk Manager in the management of risk,
including continuous review, evaluation and development of the Trust Risk Register, risk
analysis and reporting.
9) In conjunction with the Compliance Manager and Trust Risk Manager provide risk
management and risk register advice, support and training for CAG Governance Teams
and corporate risk owners and sponsors when required.
10) Manage the Trust’s Central Alert System (CAS) to include the process for receipt,
logging, dissemination, action and identification of owner accountabilities and
responsibilities.
11) To provide advice in relation to the CAS requirements of designated risk assessments
and evaluate the availability, quality/robustness and documentation of all evidence of
compliance.
12) To use Datix and other risk systems to collect, analyse and report data for CQC, risk
governance and assurance purposes
13) To support SI, incident and complaint thematic reviews and investigations when required
using Datix customised reporting and RCA techniques and other investigatory
methodologies and approaches.

2. Risk Systems Technical Maintenance
14) Deputise for the Risk Systems Coordinator where appropriate
15) To act as the Administrator for the Level of Harm Validation Group
16) To work with the Risk Systems Coordinator in performing upgrades to the Risk Systems
in conjunction with the system suppliers, ICT and end users in line with ICT regulations
and requirements and ensuring minimal disruption for users
17) Undertaking robust testing on the Test System prior to upgrade
18) In conjunction with the Risk Systems Coordinator ensure full validity of systems following
system upgrades
19) To work closely with the ICT department on the operational needs of the system and
implement these in conjunction with the Risk Systems Coordinator in order to meet the
requirements of the Trust
20) To develop and maintain the Datix System templates stored on the Server and update as
appropriate
21) To perform system installations
22) Provide second line support to end users when referred by ICT and troubleshooting any
technical issues
23) Maintain and ensure the security of all relevant systems, in use within the Trust,
including DATIX in keeping with best practice recommendations and requirements.
24) Where appropriate, review and submit data submitted electronically to designated
external bodies
25) Provide assurance in relation to the quality of data, information and reports produced
by the Department and ensure all discrepancies and significant issues are investigated
and appropriate action taken. Report as necessary to the Risk Systems Coordinator and
Patient Safety Team, prior to reporting externally to the NRLS or other external body
26) To attend users groups both internally and externally
27) Robustly monitor and deal with the queries sent to the DATIX mailbox or any other
risk systems mailbox as appropriate and provide assistance in a timely manner.
Speedily identify patterns of problems which are indicative of larger issues. To raise
these with ICT/DATIX/other system provider and/or the Business Intelligence Unit
directly and resolve and escalate where appropriate.
28) Use experience and knowledge to support colleagues in their use of governance and
risk systems, providing advice as appropriate.
29) Provide support via telephone and email to risk & governance systems users across
the Trust - addressing problems, troubleshooting any technical issues and escalating
unsolvable and serious problems to the Risk Systems Coordinator
30) Design and deliver tailored training (one to one or groups) to Trust personnel on
DATIX modules and other Risk & Governance systems operated within the Trust
Documentation Control Standing Operating Procedures and Policy Development

3. 31) To provide advice in relation to the requirements of designated assessments and
evaluate the availability, quality/robustness and documentation of all evidence of
compliance.
32) To support the Compliance Coordinator and Compliance Facilitators in the development
of new documentation, SOPs and policies, in respect of compliance and quality
governance standards.
33) Support effective management of the Barts Health Clinical Policy framework, including
preparation of polices and papers for submission to the Clinical Policy Group.
34) Provide accurate action note taking to the Clinical Policies Group and other governance
meetings as required.
35) In conjunction with the Compliance Coordinator ensure relevant documents, including
policies meet the criteria set by external agencies, liaising with ‘policy owners’ and the
chairs of relevant committees to ensure documents are in date and endorsed in keeping
with the Trust’s Policy for Policies.
36) To facilitate work streams that relate to external assessments, including the development
and evaluation of relevant audits and producing and/or monitoring of action plans to
ensure agreed actions take place.
Complaints Management
37) To undertake and support central complaints handling if required and as directed by the
Compliance Coordinator and Manager
38) To understand and be competent in carrying out central complaint functions and
processes including review and triage of the central complaints inbox, complaints
registration and acknowledgement of complaints on Datix.
Leadership and Professional Development
39) Motivate and support corporate and CAG teams to recognise their role in complying with
all external and internal assessments and governance standards.
40) To represent/deputise for the Compliance Coordinator as and when required and to
represent the Compliance Team at meetings/events within the Trust and where
appropriate with designated stakeholders and agencies under the guidance of the
Compliance Coordinator.
41) Provide training in respect of statutory compliance at all levels across the organisation,
42) using a range of media.
43) To engage in an agreed programme of personal/professional development that
contributes to personal and Trust objectives and continuous service improvement.
44) Participate in an annual performance review by having an appraisal and progressing
through the Talent and Performance Framework.
Management
45) To direct and supervise the work of the Compliance Audit Support Officer.
46) To contribute to the effective use of the departmental budget and resources.
47) To contribute to the evaluation of departmental (Compliance Unit) performance, actively
supporting the achievement of key performance indicators and departmental/corporate
objectives

4. Communication and Relationships
48) Maintain collaborative and effective team working with colleagues from corporate and
49) CAG teams, including Governance Leads to provide advice and to increase
understanding and therefore compliance with all governance standards.
50) Assist colleagues in corporate teams and CAGs by clearly setting out what is required to
meet statutory requirements and best practice guidance, taking advice from the
Compliance Coordinator. Make suggestions/recommendations as to what constitutes
good evidence, highlighting gaps and risks to compliance.
Education, Research and Development
51) Actively seek out best practice models from within the NHS and elsewhere and
participate in benchmarking and research in the area of governance standards and risk
reduction.