Compliance and Quality Improvement Manager

Job description

Job responsibilities

Whittington Health NHS Trust

Job Description

Job Title: Compliance and Quality Improvement ManagerBand: 8aHours: 37.5 per weekDepartment: Nursing and Patient ExperienceBase: Whittington HospitalReports to: Associate Director of Quality GovernanceAccountable to: Deputy Chief Nurse

Job Summary

The Compliance and Quality Improvement Manager is responsible for developing, implementing, and managing the Trusts compliance and quality improvement frameworks to ensure adherence to Care Quality Commission (CQC) standards and other regulatory requirements. The post holder will lead compliance programmes, conduct deep dive reviews, coordinate peer reviews and mock inspections, and drive a culture of continuous improvement across Whittington Health.

This role requires close collaboration with Executive Directors, Clinical Divisions and governance teams to monitor, evaluate, and enhance compliance performance. The post holder will also oversee policy reviews, manage regulatory communications, and ensure the Trust is fully prepared for inspections.

This role requires a visible and accessible leader which will require the post holder to be on site as part of a flexible working agreement

Key Responsibilities

Regulatory Compliance and Governance

• Act as the Trusts professional lead on regulatory compliance, maintaining up-to-date knowledge of CQC and other regulatory frameworks.
• Lead on developing and implementing a structured compliance programme, including annual and responsive compliance reviews.
• Oversee a programme of peer reviews, mock inspections, and self-audits across all services.
• Analyse findings, identify areas for improvement, and ensure timely implementation of remedial action plans.
• Develop and maintain strong working relationships with external regulators, including the CQC Relationship Manager.
• Produce and present compliance reports, dashboards, and exception analyses to Governance Committees, including the Quality Committee, Audit and Risk Committee, and Patient Safety Committee.
• Coordinate the production of the Annual Compliance, Governance, and Risk Report in collaboration with governance colleagues.
• Ensure that compliance evidence and documentation are current, accurate, and readily accessible for regulatory assessments.
• Work with senior management to embed compliance and risk management into clinical and operational practices.
• Service the Trusts Quality Governance Committee (QGC) and Quality Assurance Committee (QAC) providing support to the chair.
• Lead on the annual development and monitoring of the Trusts Quality Account.

Audit & Quality Improvement

• Lead on identifying, implementing, and monitoring quality improvement initiatives linked to regulatory compliance and patient safety.
• Support services in developing action plans and measurable improvements following audits, inspections, and investigations.
• Facilitate service deep dives and thematic reviews to inform targeted quality improvement activities.
• Support and advise clinical and non-clinical teams on compliance and governance best practices, using data-driven insights to improve performance.
• Oversee the Trusts Tendable audit schedule and reporting.
• Implement and manage the Trusts ward accreditation programme.

Policy and Process Management

• Oversee a structured programme for systematic review and updating of all Trust policies and standard operating procedures.
• Ensure alignment of Trust policies with regulatory standards, governance requirements, and national guidance.

Communication and Engagement

• Work with the Communications and Nursing teams to ensure consistent and effective messaging around quality and compliance.
• Develop internal and external materials for inspection readiness, including presentations and information packs for the CQC.
• Oversee logistical and communication preparations for inspections and visits, ensuring all areas of the Trust are inspection-ready.

Leadership and Collaboration

• Work collaboratively with senior leaders and divisional teams to develop compliance capability and accountability within services.
• Support the Chief Medical Officer , Nursing, and Patient Experience teams to ensure medical and clinical staff are fully engaged in quality and compliance improvement.
• Develop networks with other provider Trusts to share learning and best practice.
• Line management of staff where required.

Decision-Making and Professional Standards

• Make independent decisions within the scope of the role to ensure regulatory compliance and escalate significant issues appropriately.
• Promote and uphold the Trusts values and commitment to quality, patient safety, and continuous improvement.
• Ensure compliance with Trust policies on Equality, Diversity and Inclusion, Safeguarding, Infection Control, Health and Safety, Data Protection, and Confidentiality.

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

Person Specification

Attribute

Essential

Desirable

Assessment

Qualifications

Masters degree or equivalent experience

Registered professional qualification

A/I

Willingness to undertake CPD

A/I

Experience

Minimum 5 years NHS experience

A

Demonstrable experience of leading regulatory compliance and quality improvement in a complex environment

A/I

Experience in integrated governance, risk management, and advising senior management

A/I

Experience managing teams within a regulatory framework

A/I

Experience working with CQC or equivalent regulatory bodies

A/I

Experience developing and delivering training programmes

A/I

Skills and Abilities

Excellent oral and written communication

A/I

Strong interpersonal, influencing, and negotiation skills

A/I

Highly developed analytical and problem-solving skills

A/I

Project management and strategic planning ability

A/I

Proficiency in IT and database management

A/I

Ability to analyse complex information and make sound decisions

A/I

Knowledge

In-depth knowledge of NHS structures, policies, and CQC regulations

I

Understanding of integrated governance, audit, and risk management

I

Familiarity with NICE guidance and quality improvement methodologies

I

Personal Qualities

Strong leadership and motivational skills

A/I

Commitment to quality, safety, and patient-centred care

A/I

Adaptable, proactive, and resilient

A/I

Self-motivated and innovative thinker

A/I

Additional Information

• The post holder must adhere to the Trusts values, policies, and procedures at all times.
• This role includes responsibilities under the Data Protection Act, Equality Act, and Safeguarding legislation.
• The post holder must be willing to work flexibly, including occasional out-of-hours work, to meet organisational needs.

Person Specification

Qualifications

Essential

• Master's degree or equivalent experience
• Willingness to undertake CPD

Desirable

• Registered professional qualification

Experience

Essential

• Minimum 5 years NHS experience
• Demonstrable experience of leading regulatory compliance and quality improvement in a complex environment
• Experience in integrated governance, risk management, and advising senior management
• Experience managing teams within a regulatory framework
• Experience working with CQC or equivalent regulatory bodies
• Experience developing and delivering training programmes

Skills

Essential

• Excellent oral and written communication
• Strong interpersonal, influencing, and negotiation skills
• Highly developed analytical and problem-solving skills
• Project management and strategic planning ability
• Proficiency in IT and database management
• Ability to analyse complex information and make sound decisions

Knowledge

Essential

• In-depth knowledge of NHS structures, policies, and CQC regulations
• Understanding of integrated governance, audit, and risk management
• Familiarity with NICE guidance and quality improvement methodologies

Personal Qualities

Essential

• Strong leadership and motivational skills
• Commitment to quality, safety, and patient-centred care
• Adaptable, proactive, and resilient
• Self-motivated and innovative thinker

Disclosure and Barring Service Check

This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.

Certificate of Sponsorship

Applications from job seekers who require current Skilled worker sponsorship to work in the UK are welcome and will be considered alongside all other applications. For further information visit the UK Visas and Immigration website (Opens in a new tab).

From 6 April 2017, skilled worker applicants, applying for entry clearance into the UK, have had to present a criminal record certificate from each country they have resided continuously or cumulatively for 12 months or more in the past 10 years. Adult dependants (over 18 years old) are also subject to this requirement. Guidance can be found here Criminal records checks for overseas applicants (Opens in a new tab).

Employer details

Employer name

Whittington Hospital NHS Trust

Address

Whittington Hospital

Archway

N19 5NF

Employer's website

https://www.whittington.nhs.uk/ (Opens in a new tab)