• Job Description

  Req#: B9074-25-0027?language=en&page=374&sort=publicationDateDesc

  Job summary

  If you would like to work in a Quality and Governance role, an exciting opportunity has arisen at CSH Surrey as an Improvement, Experience and Effectiveness Administrator Band 4, on a WTE basis (37.5 hours per week), based in Dukes Court, Woking. You may be required to travel to other bases for meetings. The post holder will report to the Improvement Experience and Effectiveness Manager.

  You will contribute to the implementation of robust assurance and oversight processes and improvement approaches to ensure quality care that is responsive, safe, effective and promotes a positive experience of care.

  The post holder will be responsible for managing a wide range of administrative and clerical tasks relating to patient experience, clinical effectiveness and quality improvement, undertaking complex responsibilities and working across all services provided by CSH Surrey effectively and efficiently.

  You will be responding to telephone calls and emails as the initial point of contact for frequent and unpredictable enquiries from our service users sharing their service user experience, reporting complaints and compliments.

  An excellent working knowledge of Excel, report writing and attention to detail is required. A knowledge of the Datix system or similar risk management database is desirable.

  If you would like to discuss this role, please email - Sarah Taylor Improvement Experience and Effectiveness Manager: Sarah.Taylor30@nhs.net.

  Main duties of the job

  You will need to assimilate complex and unfamiliar information quickly and provide appropriate advice to all contact with the service. You will need the ability to respond to competing priorities and remain focused and effective.

  You will support with the implementation and monitoring of the patient experience and engagement strategy across CSH Surrey Services.

  You will support and train other staff in core functions including complaints assessment and management, clinical audit preparation and reporting, and quality improvement project reporting.

  To lead the continual review and evaluation of all administrative systems and procedures and associated policies, to support the quality agenda.

  Please note: An enhanced DBS check with both the Children and Adults Barred Lists is required for this role. If the successful candidate does not currently hold this level of clearance, the check will be carried out as part of the pre-employment process.

  About us

  CSH Surrey are part of the NHS and are Surreys largest and longest established NHS community services provider. Our employees receive NHS pay and pension, and also receive the Fringe High-Cost Allowance of 5%.

  Our staff enjoy excellent training and development opportunities, including the care certificate, apprenticeships, numeracy and literacy courses, access to the Nursing Associate programme, and a wide variety of management and leadership courses and programmes.

  We CARE about our staff though through our values of Compassion, Accountability, Respect and Excellence. Our active employee council called The Voice, elect employee representatives to ensure colleagues' voices are heard at Board level. CSH is a diverse organisation, if you are a passionate, person-focused individual then apply to join CSH Surrey today!

  We welcome candidates from all backgrounds who meet the essential criteria of the job you are applying for and if you require any reasonable adjustments, please contact the named individual for this advert, or our recruitment team.

  Date posted

  14 April 2025

  Pay scheme

  Agenda for change

  Band

  Band 4

  Salary

  £27,857 to £30,570 a year Includes 5% HCA. Both are pro-rata per annum if part-time

  Contract

  Permanent

  Working pattern

  Flexible working

  Reference number

  B9074-25-0027

  Job locations

  4th Floor, Dukes Court

  Dukes Street

  Woking

  Surrey

  GU21 5BH

  
  

  Job description

  Job responsibilities

  Quality & Governance Team Operation

  Ensure that all public and professional enquiries are dealt with in an efficient, polite, and confidential manner and/or passed onto the relevant colleague for action.

  To prioritise and take responsibility for own work load and recognise and support colleagues who need training, guidance and assistance.

  Co-ordinate and monitor annual leave and absence management processes, statutory and mandatory training attendance and other HR policies.

  Securely maintain the personnel records of the Quality & Governance team in accordance with the confidentiality policy, data protection act and management of personnel files policy.

  Maintain emergency contact details for the purpose of emergency planning and safe working practices of peripatetic co-owners.

  To participate in the initial stages of performance management, grievance and discipline procedures, when appropriate.

  Participate in the investigation of any internal or external complaints relating to the Quality & Governance team in line with the CSH Surrey complaints policy and lead on any administrative complaints or queries.

  Estates, Procurement and Business Continuity

  Purchase, manage and monitor appropriate level of stationary and office supplies within the budget allocated and ensure that stocks are stored securely.

  Be aware of the emergency planning and business continuity policies and plans, and comply with the prescribed actions detailed within in the event of an emergency/significant event.

  Support to the Quality & Governance Team

  Provide, investigate and analyse complex statistical and audit information as requested by Quality & Governance team members.

  To act as IT Champion to the Quality & Governance team to promote the development of IT based processes and extend the use of IT systems to create efficiencies.

  Undertake complex/confidential tasks to be delivered including liaising with multiple professionals in the planning and co-ordination of quality improvements projects, carrying out regular audits & analysis of the information, development of complex reports, documents, graphs, data collection/spreadsheets.

  Lead the development and implementation of a standardised process for filing reports and data maintenance ensuring data is stored appropriately and electronically where possible, to comply with the information governance policy.

  Lead the maintenance and development of the Quality & Governance pages of the intranet & website.

  Administer the full process for safety alerts and Central Alerting System (CAS) website, including logging, assessment, distribution, collating responses, and action completion confirmations and closing the alerts in Datix and on the CAS website.

  Lead the CSH Surrey Policy review process by leading the updating of the CSH Surrey Datix policy database, formatting and updating policies and operating a review process for all policies.

  Maintain log of notifications to the Care Quality Commission CQC.

  Maintain a knowledge base of all services and activities delivered by the Quality & Governance team.

  Provide cover for administration tasks for Patient Experience Team and the administration of Subject Access Requests.

  Have a detailed knowledge of a specific range of services across CSH Surrey.

  Manage an efficient and effective administrative and secretarial service to the members of the Quality & Governance team, acting as a specialist administrative resource in the co-ordination and delivery of often complex procedures and reporting.

  To manage the often complex and conflicting queries in the Quality & Governance email inboxes ensuring messages are responded to in the first place, or passed onto the relevant team member.

  Arrange meetings on behalf of Quality & Governance team members.

  To coordinate Quality & Governance group/committee meetings including: compiling agendas, coordinating reports and attending, as required, for completion of minutes. This may include:

  Quality and Clinical Governance Group

  Infection Prevention and Control Group

  Serious Incident Review Group

  Clinical Practice Forums

  To deputise for the Quality Improvement Manager in their absence.

  Financial Responsibilities

  To manage any petty cash allocation for the Quality & Governance team.

  To purchase supplies and equipment required for the effective running of the service within the budget allocated.

  To monitor stock levels and ensure sufficient supplies are available for the effective running of the service.

  Ensure that invoices for goods and services received are processed for payment from the correct cost centre expediently to enable payment to be made within terms and conditions agreed with each supplier.

  Communication / emotional effort

  Work to CSH Surrey mission, vision and values.

  Receive and communicate distressing, emotional, complex or sensitive information both internally and externally in line with the information governance policy. This will mainly arise from the frequent handling of incidents, serious incidents and safeguarding issues.

  Personal Development

  Identify and take responsibility for own learning requirements in relation to the provision of an efficient service.

  Maintain and continually advance own knowledge of and skills in using software packages and system and process improvement methodologies.

  Keep up to date with relevant developments in administrative systems and processes and clinical services.

  Attend statutory and mandatory training to maintain compliance.

  Participate in the performance development review process.

  Foster a learning culture by ensuring that lessons are learnt from mistakes and near misses.

  To maintain an up-to-date knowledge of risk management and of the Datix system and to continuously develop professional knowledge and competence.

  Job description

  Job responsibilities

  Quality & Governance Team Operation

  Ensure that all public and professional enquiries are dealt with in an efficient, polite, and confidential manner and/or passed onto the relevant colleague for action.

  To prioritise and take responsibility for own work load and recognise and support colleagues who need training, guidance and assistance.

  Co-ordinate and monitor annual leave and absence management processes, statutory and mandatory training attendance and other HR policies.

  Securely maintain the personnel records of the Quality & Governance team in accordance with the confidentiality policy, data protection act and management of personnel files policy.

  Maintain emergency contact details for the purpose of emergency planning and safe working practices of peripatetic co-owners.

  To participate in the initial stages of performance management, grievance and discipline procedures, when appropriate.

  Participate in the investigation of any internal or external complaints relating to the Quality & Governance team in line with the CSH Surrey complaints policy and lead on any administrative complaints or queries.

  Estates, Procurement and Business Continuity

  Purchase, manage and monitor appropriate level of stationary and office supplies within the budget allocated and ensure that stocks are stored securely.

  Be aware of the emergency planning and business continuity policies and plans, and comply with the prescribed actions detailed within in the event of an emergency/significant event.

  Support to the Quality & Governance Team

  Provide, investigate and analyse complex statistical and audit information as requested by Quality & Governance team members.

  To act as IT Champion to the Quality & Governance team to promote the development of IT based processes and extend the use of IT systems to create efficiencies.

  Undertake complex/confidential tasks to be delivered including liaising with multiple professionals in the planning and co-ordination of quality improvements projects, carrying out regular audits & analysis of the information, development of complex reports, documents, graphs, data collection/spreadsheets.

  Lead the development and implementation of a standardised process for filing reports and data maintenance ensuring data is stored appropriately and electronically where possible, to comply with the information governance policy.

  Lead the maintenance and development of the Quality & Governance pages of the intranet & website.

  Administer the full process for safety alerts and Central Alerting System (CAS) website, including logging, assessment, distribution, collating responses, and action completion confirmations and closing the alerts in Datix and on the CAS website.

  Lead the CSH Surrey Policy review process by leading the updating of the CSH Surrey Datix policy database, formatting and updating policies and operating a review process for all policies.

  Maintain log of notifications to the Care Quality Commission CQC.

  Maintain a knowledge base of all services and activities delivered by the Quality & Governance team.

  Provide cover for administration tasks for Patient Experience Team and the administration of Subject Access Requests.

  Have a detailed knowledge of a specific range of services across CSH Surrey.

  Manage an efficient and effective administrative and secretarial service to the members of the Quality & Governance team, acting as a specialist administrative resource in the co-ordination and delivery of often complex procedures and reporting.

  To manage the often complex and conflicting queries in the Quality & Governance email inboxes ensuring messages are responded to in the first place, or passed onto the relevant team member.

  Arrange meetings on behalf of Quality & Governance team members.

  To coordinate Quality & Governance group/committee meetings including: compiling agendas, coordinating reports and attending, as required, for completion of minutes. This may include:

  Quality and Clinical Governance Group

  Infection Prevention and Control Group

  Serious Incident Review Group

  Clinical Practice Forums

  To deputise for the Quality Improvement Manager in their absence.

  Financial Responsibilities

  To manage any petty cash allocation for the Quality & Governance team.

  To purchase supplies and equipment required for the effective running of the service within the budget allocated.

  To monitor stock levels and ensure sufficient supplies are available for the effective running of the service.

  Ensure that invoices for goods and services received are processed for payment from the correct cost centre expediently to enable payment to be made within terms and conditions agreed with each supplier.

  Communication / emotional effort

  Work to CSH Surrey mission, vision and values.

  Receive and communicate distressing, emotional, complex or sensitive information both internally and externally in line with the information governance policy. This will mainly arise from the frequent handling of incidents, serious incidents and safeguarding issues.

  Personal Development

  Identify and take responsibility for own learning requirements in relation to the provision of an efficient service.

  Maintain and continually advance own knowledge of and skills in using software packages and system and process improvement methodologies.

  Keep up to date with relevant developments in administrative systems and processes and clinical services.

  Attend statutory and mandatory training to maintain compliance.

  Participate in the performance development review process.

  Foster a learning culture by ensuring that lessons are learnt from mistakes and near misses.

  To maintain an up-to-date knowledge of risk management and of the Datix system and to continuously develop professional knowledge and competence.

  Person Specification

  Qualifications

  Essential

  • Educated to A level
  • NVQ level 3
  • RSA, Higher diploma with a good basic education to include maths and English, plus evidence of administrative knowledge and skills equivalent to level of qualification

  Desirable

  • Willingness to train/ develop further skills

  Experience

  Essential

  • -Knowledge of a range of policies and management procedures. This
  • will require further on the job training and experience.
  • -Proven experience of delivering a wide range of administration tasks
  • to a high standard in a patient / service focused environment.
  • -Experience of using complex software packages/databases.
  • -Experience of data analysis
  • -Ability to interpret and summarise data effectively, producing reports,
  • creating tables and graphs.
  • -Experience of the delivery of objectives within a constantly changing
  • environment.
  • -Setting up and using IT data collection formats and databases to
  • produce reports for management information.
  • -Knowledge of protection legislation data.

  Desirable

  • -Knowledge of business management procedures.
  • -Experience in using the Datix system.
  • -Experience in using the Central Alerting System.
  • -Involvement in audit and in setting up and monitoring projects/new
  • developments and an understanding of quality issues.
  • -Experience of understanding of service level agreements and key
  • performance indicators and their correlation to business aims and
  • objectives.
  • -Advanced knowledge of Microsoft Office; proficient in Excel pivot tables

  Person Specification

  Qualifications

  Essential

  • Educated to A level
  • NVQ level 3
  • RSA, Higher diploma with a good basic education to include maths and English, plus evidence of administrative knowledge and skills equivalent to level of qualification

  Desirable

  • Willingness to train/ develop further skills

  Experience

  Essential

  • -Knowledge of a range of policies and management procedures. This
  • will require further on the job training and experience.
  • -Proven experience of delivering a wide range of administration tasks
  • to a high standard in a patient / service focused environment.
  • -Experience of using complex software packages/databases.
  • -Experience of data analysis
  • -Ability to interpret and summarise data effectively, producing reports,
  • creating tables and graphs.
  • -Experience of the delivery of objectives within a constantly changing
  • environment.
  • -Setting up and using IT data collection formats and databases to
  • produce reports for management information.
  • -Knowledge of protection legislation data.

  Desirable

  • -Knowledge of business management procedures.
  • -Experience in using the Datix system.
  • -Experience in using the Central Alerting System.
  • -Involvement in audit and in setting up and monitoring projects/new
  • developments and an understanding of quality issues.
  • -Experience of understanding of service level agreements and key
  • performance indicators and their correlation to business aims and
  • objectives.
  • -Advanced knowledge of Microsoft Office; proficient in Excel pivot tables

  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.

  Employer details

  Employer name

  CSH Surrey

  Address

  4th Floor, Dukes Court

  Dukes Street

  Woking

  Surrey

  GU21 5BH

  
  

  Employer's website

  https://www.cshsurrey.co.uk/about-us/about-csh-surrey (Opens in a new tab)

  Employer details

  Employer name

  CSH Surrey

  Address

  4th Floor, Dukes Court

  Dukes Street

  Woking

  Surrey

  GU21 5BH

  
  

  Employer's website

  https://www.cshsurrey.co.uk/about-us/about-csh-surrey (Opens in a new tab)

• About the company

  National Health Service (NHS) is the umbrella term for the publicly-funded healthcare systems of the United Kingdom (UK). The founding principles were that services should be comprehensive, universal and free at the point of delivery—a health service based on clinical need, not ability to pay. Each service provides a comprehensive range of health services, free at the point of use for people ordinarily resident in the United Kingdom apart from dental treatment and optical care.

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