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1.      To be responsible for leading the CDC’s through the accreditation process for the services being provided, working with the accreditation team and service leads, and that the service then maintains accreditation. 

2.      To complete the web-based electronic assessment process and complete this annually following accreditation. 

3.      To coordinate the service’s responses to the United Kingdom Accreditation Service (UKAS), ensuring that all evidence uploaded to the specialities web based assessment is relevant, up-to-date, and fully meets the set criteria. 

4.      To work closely with the Senior Operations Manager, Clinical Governance Lead Matron and speciality leads, to ensure that governance and safety standards are maintained in line with Trust and UKAS requirements. 

5.      To work with Speciality Team Leads, the Senior Leadership team and Clinical Leads to coordinate relevant audits and evidence requirements of each standard, promoting a culture of continuous quality improvement within each speciality. 

6.      To process, review and analyse highly complex information, including statistical data and audit information, to inform and advise on governance standards and processes.  

7.      To be knowledgeable on the requirements of the individual standards and advise other members of staff as to expectations with regards to standards of practice and evidence.  

8.      Present audits and governance topics at speciality and other governance meetings. 

9.      Have overarching accountability for ensuring that all the CDC protocols, policies, guidelines and patient information leaflets are maintained as relevant, current and up to date. 

10.   To ensure all documentation is benchmarked and in line with national guidelines and best practice evidence, implementing changes to processes and procedures in the CDC. 

11.   To support Speciality Leads and staff in achievement of action plans and mandatory findings in relation to Trust quality and safety audits, and accreditation mandatory findings. 

12.   To support the Senior Operations Manager in organising quarterly CDC governance meetings. 

13.   Support the Senior Operations Manager in managing risk assessments and the risk register.  

14.   Formulate annual governance reports and regular dashboard reports in conjunction with the Senior Operations Manager. 

15.   To utilise and analyse complex statistics and reports relevant to accreditation standards. 

16.   Maintain standards in accordance with accreditation requirements. 

17.   Work with the Modality Leads and Leadership team to implement quality and service improvements. 

18.   To work to deadlines and be prepared to work flexibly. 

19.   To be an authorised signatory for small financial expenditures in relation to resources required for governance and accreditation purposes.  

20.   To work closely with the Speciality Leads and Operational Managers to ensure appropriate financial resourcing of governance and accreditation activities. 

21.   To manage the financial budget to support the accreditation requirements.