Mortuary Quality and Audit Lead - London, United Kingdom - Croydon Health Services NHS Trust

Description

The post holder will be required to act as quality lead for the department, reviewing and updating all documentation associated with Mortuary activity. As quality lead the post holder will be expected to work autonomously and lead on all departmental audits, ensuring audits are performed to the agreed schedule.

The post holder will be required to produce monthly quality reports using statistical data to show performance and compliance with regulations. The post holder will attend quality and governance meetings presenting Mortuary performance reports and reporting back to the manager and team were applicable.

The post holder will assist the Mortuary manager with all aspects of regulatory compliance. The post holder will act as persons designated for the HTA licence. The post holder will assist the team with the smooth running of the service, ensuring there is suitable capacity across the Trust and that Post Mortem services are delivered accordingly.

Main duties of the job The post holder will be required to act as quality lead for the department, reviewing and updating all documentation associated with Mortuary activity. As quality lead the post holder will be expected to work autonomously and lead on all departmental audits, ensuring audits are performed to the agreed schedule.

The post holder will be required to produce monthly quality reports using statistical data to show performance and compliance with regulations. The post holder will attend quality and governance meetings presenting Mortuary performance reports and reporting back to the manager and team were applicable.

The post holder will assist the Mortuary manager with all aspects of regulatory compliance. The post holder will act as persons designated for the HTA licence. The post holder will assist the team with the smooth running of the service, ensuring there is suitable capacity across the Trust and that Post Mortem services are delivered accordingly. About us Croydon Health Services provides integrated NHS services to care for people at home, in schools, and health clinics across the borough as well as at Croydon University Hospital and Purley War Memorial Hospital.

CUH provides more than 100 specialist services and is home to the borough's only Emergency Department and 24/7 maternity services, including a labour ward, midwifery-led birth centre and the Crocus home birthing team.

Purley War Memorial Hospital (PWMH) in the south of the borough offers outpatient care, including diagnostic services, physiotherapy and ophthalmology services run by Moorfields Eye Hospital, alongside an onsite GP surgery.

Our experienced district nursing teams, Allied Health Professionals and community matrons look after for people of all ages across Croydon and our Children's Hospital at Home cares for children with long-term conditions without them having to come to hospital.

We are a very close-knit and friendly organisation where everyone of our 3600 members of staff is valued. We strongly believe that our employees are our greatest asset. Job description Job responsibilities

• The post-holder is accountable to the Mortuary manager
• To act as lead in quality management for the Mortuary and Post Mortem service.
• To work autonomously to ensure that all policies and procedures are maintained and comply with regulatory and Trust requirements.
• To review and update all policies and procedures in line with regulatory updates and agreed review timelines.
• To produce new policies and procedures that reflect change in practice and assist the manager with effective change management processes.
• To undertake vertical, horizontal and observation audits, in line with the agreed audit schedule.
• To work with the manager to develop appropriate audit schedules that cover all aspects of regulatory compliance.
• To work with the manager and lead on staff competency audits in line with agreed training programs and the RISPH APT qualifications.
• To report process deviations to the manager and assist with the completion of error logs and CAPA plans.
• Organising regular Mortuary staff meetings, planning agenda items and circulating action plans.
• Representing the Mortuary at quality and clinical governance meetings.
• To work with the manager to ensure all incidents and near misses are appropriately reported.
• To investigate incidents and produce reports and action plans reporting back to the Mortuary manager with timelines and findings.
• To assist the manager with delivering the Coroners contract for post mortem activity, showing performance against agreed contractual KPIs.
• To ensure that all Mortuary records are up to date and well maintained.
• To supervise staff in all aspects of Mortuary work, ensuring compliance with procedures and associated risks.

If required assist the team to ensure efficient running of the Post Mortem room and delivery

To investigate incidents and produce reports and action plans reporting back to the Mortuary manager with timelines and findings.

• To assist the manager with delivering the Coroners contract for post mortem activity, showing performance against agreed contractual KPIs.
• To ensure that all Mortuary records are up to date and well maintained.
• To supervise staff in all aspects of Mortuary work, ensuring compliance with procedures and associated risks.
• If required assist the team to ensure efficient running of the Post Mortem room and delivery of Post Mortem services and department when staff shortage occurs
• Audit the cleaning and disinfection of the department in line with the agreed procedures and records.
• To research and implement new equipment and consumables.
• To assist the manager and supervise staff ensuring appropriate use of equipment and consumables.
• To work with the manager to deliver savings targets.

Assist the manager with annual reviews of policies and procedures, including all risk and COSHH assessments.

• To preform monthly health and safety audits.
• To complete monthly fire audits.
• To check all first aid equipment is complete and in date, ordering replacements when required.
• To review and assist with implementation related to new information relevant to infection control.
• To be a departmental first aid officer and undertake training in basic life support.
• Assist the Mortuary manager in the delivery of training to all staff in the Mortuary.
• To act as a mentor where applicable for trainee APTs
• To assist the Mortuary manager with updating and delivering training to external personnel such as ward staff, pottering staff and bed managers.
• To complete annual appraisals with allocated members of the team.
• To assist in the identification of development and training opportunities for the Mortuary staff.

Out of Hours

• To participate in the On-Call out of Hours service for the Coroner/Hospital. To be available to the Coroner/Hospital should there be a Forensic Post Mortem.
• To be available whenever possible to answer hospital enquiries and outside family or Police enquires
• To attend the hospital for Major Incident
• To attend the mortuary out of normal working hours as required.
• To facilitate official police identifications as required.
• To attend Mortuary to assist in tissue donation services

Specific Additional Responsibilities

Training

• To ensure that all Trust and Departmental Protocols are adhered to and updated and reviewed as necessary
• To maintain and develop skills appropriate to the role by attending appropriate training courses supplied by the Trust, HTA, Tissue Donation, AAPT
• Use knowledge and experience to enhance post mortem procedures and techniques on all deceased to include high-risk infectious cases via Diploma standard training and other acquired knowledge
• Participation in the annual PDP process
• Training of junior personnel in the post mortem processes and all mortuary aspects

Health and Safety

• Responsible in safety supervision and to ensure that safe working practices are followed
• To ensure that staff conform to the Health & Safety Code of Practice
• Health and Safety training and awareness of current policy and changes in Health and Safety Law

Person Specification Education and Qualification Essential

• HTA Consent training
• Previous Mortuary SOP and Audit experience
• Educated to degree level or equivalent experience.
• Further evidence of post graduate knowledge training or experience

Desirable

• Leadership qualifications. Audit training. Risk training. CAPA training

KNOWLEDGE AND UNDERSTANDING Essential

• Full working knowledge of a Mortuary and Post Mortem room.
• Full working knowledge of the HTA and the appropriate regulatory codes and standards.
• Full knowledge and understanding of Mortuary quality management

EXPERIENCE Essential

• Experience in a Mortuary and Post Mortem room at a senior level
• Hands on experience in all aspects of Mortuary work.
• Hands on experience of Post Mortem examinations.
• Experience producing SOP's, Risk Assessments, and audits.
• Experience producing and updating excel spreadsheets.
• Experience of compliance, quality improvement or governance
• Experience in Audits
• Experience of analysing complex data and information
• Experience of presenting complex information and reports

Desirable

• Experience of delivering education and training sessions in a variety of formats

SKILLS/ABILITIES Essential

• To work in accordance with Departmental and Trust protocols.
• Computer literate
• To develop personal skills and knowledge.
• Team leader/Supervisory skills.
• Good verbal communication skills with ability to be sensitive, tactful and diplomatic
• Ability to liaise effectively with others and supervise individuals Able to concentrate intensely for long periods of time
• Able to prioritise work and meet strict deadlines
• Proactive problem solving skills
• Able to work on own initiative and as part of a team
• Able to understand and respond to complex issues and recognise when these need to be escalated
• Full driving licence with access to own transport and to drive mortuary transport vehicle

Desirable

• Knowledge of Cerner or other pathology data bases.

Employer details Employer name Croydon Health Services NHS Trust Address Croydon University Hospital

London Road

Croydon

CR7 7YE Any attachments will be accessible after you click to apply. 199-NN E&A
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