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TheCompliance Manager will be responsible for ensuring the GP Federation maintains the highest standards of regulatory compliance across all areas of its operations. This role will lead on Care Quality Commission (CQC) compliance, oversee the development and maintenance of the Quality Compliance System (QCS) portal, implement and review policies and procedures, conduct internal audits, and provide assurance to the Board and CEO that compliance standards are met. The postholder will also oversee the Federation's risk register, ensuring risks are identified, assessed, monitored, and reported appropriately. They will work closely with operational teams, service managers, and clinical leaders to embed a culture of compliance, risk awareness, and quality throughout the organisation.

• Regulatory and Organisational Compliance
• Audits and Assurance
• Training and Staff Development
• Collaboration and Engagement
• Risk and Governance

Please refer to the main job description and attached documentation.

The East Lancashire Alliance is a network of 9 PCNs covering 48 GP practices covering a population of over 390,000 patients across East Lancashire. Patients are at the heart of everything we do, and we pride ourselves in ensuring our patients feel safe, supported, communicated with and respected at a time when they may be feeling vulnerable. The Alliance are proud to represent our member practices and to champion our Primary Care Partners, by working with local general practice and other system partners in the provision of patient centred, local healthcare services.

Each practice has a close-knit team of staff who collectively seek to improve the health of their patient populations. East Lancashire is one of the world's most innovative, original, and exciting places to live and work.

Roles and Responsibilities

• Lead on CQC compliance, ensuring the organisation is fully prepared for inspections.
• Maintain and oversee the QCS portal, ensuring it remains up to date and reflective of current requirements.
• Develop, review, and implement organisational policies and procedures in line with legislation and regulatory frameworks.
• Monitor compliance across services and departments, ensuring adherence to policies, procedures, and contractual obligations.
• Prepare compliance reports and updates for the CEO, Board, and subcommittees

• Develop and maintain an annual audit calendar, ensuring audits are scheduled, conducted, and outcomes reported in a timely manner.
• Deliver a rolling programme of audits across the Federation to monitor compliance with policies, procedures, and regulatory standards.
• Monitor and track audit outcomes, ensuring remedial actions are implemented and embedded.
• Develop SMART action plans based on audit and review findings to drive company-wide continuous improvement, while providing the CEO and Board with assurance on compliance risks and areas requiring improvement
• Undertake Quality and Compliance Audits in line with regulatory, contractual and company requirements
• To raise safeguarding or serious non compliance and risk issues to the Service Manager and Assistant Director (Care and Support) immediately
• Support Managers and staff, where reasonably practicable, with local authority, CQC, quality monitoring visits and returns as directed

• Develop and deliver compliance training programmes tailored to different staff roles.
• Ensure all staff receive compliance training appropriate to their responsibilities.
• Support managers in embedding compliance awareness into day-to-day operations.
• Communicate clearly with departments and services on compliance expectations and updates to standards.

• Work closely with service managers, operational teams, and clinical directors to ensure compliance requirements are met across all service areas.
• Provide expert compliance advice and guidance to staff at all levels.
• Support cultural change initiatives to ensure compliance is seen as integral to quality and patient safety.

• Maintain and manage the organisational risk register, ensuring risks are identified, assessed, monitored, and mitigations are in place.
• Ensure regular review of the risk register, with escalation of significant risks to the CEO and Board.
• Identify compliance risks and escalate through governance processes as appropriate.
• Contribute to governance frameworks and assurance mechanisms.
• Ensure evidence of compliance is systematically recorded and accessible.
• Conducting risk assessments across all departments and services

• Work closely with the Operations Manager to ensure organisational compliance across departments, services, and workforce.
• Ensure onboarding and training requirements for compliance are fulfilled during new starter processes.
• Signpost staff to guidance and advice on policies and CQC standards
• Ensure the most up to date policy and associated documents are accessible and used appropriately in practice
• Promote and share best practice across care and support
• Undertake and support quality development workshops as required
• Take responsibility for departmental projects and/or functions as agreed with the Operations Manager
• Assist with the implementation of patient / staff satisfaction survey

• Ensure learning opportunities meet the requirements of CQC standards
• Ensure all staff are up to date with training to meet compliance with CQC
• Ensure all training records are up to date

Accountability

The post holder will be aware of the various statutory requirements and will assist in implementation as directed.

Training requirements will be monitored by yearly appraisal. Personal development will be encouraged and supported by the organisation. It is the individuals responsibility to remain up to date with recent developments.

Working Conditions

• Use of Visual Display Unit (VDU) and photocopier on a daily basis.

Physical Effort

• Light physical effort.

Mental and Emotional Effort

• Working with sensitive, highly confidential and occasionally distressing information.
• Problem solving.
• Must manage multiple tasks within a work pattern that is demanding and unpredictable.
• Priorities can change throughout the day.
• Some tasks that require high levels of concentration (i.e. transcribing, setting up and working on databases and spreadsheets).

Responsible for managing own workload, autonomous working conditions with little or no direction and no direct supervision on the work being carried out

Health & Safety/Security

Compliance with the Health & Safety at Work Act 1974. The post holder will be required to support in the management of risks. This entails the risk management of all situations, taking appropriate actions and reporting all incidents, near misses and hazards as well as a statutory duty of care for their own personal safety and that of others who may be affected by their acts or omissions.

Confidentiality

In the course of every employee's duties, they may have access to confidential material about patients, members of staff or other health service business. On no account must information relating to identifiable patients be divulged to anyone other than authorised persons, for example, medical, nursing or other professional staff, who are concerned directly with the care, diagnosis and/or treatment of the patient. Similarly, information relating to staff records or information concerning contracts, and other commercially sensitive matters etc. are considered to be confidential and must not be divulged without prior authority. Breaches of confidentiality will result in disciplinary action. If in any doubt whatsoever as to the authority of a person or body asking for information of this nature, seek advice from your manager.

The post-holder will support the equality, diversity and rights of patients, carers and colleagues, to include:

• Acting in a way that recognises the importance of peoples rights, interpreting them in a way that is consistent with procedures and policies, and current legislation
• Respecting the privacy, dignity, needs and beliefs of patients, carers and colleagues
• Behaving in a manner which is welcoming to and of the individual, is non-judgmental and respects their circumstances, feelings priorities and rights.

Everyone has a personal responsibility to seek to improve their own and colleagues working lives to create a healthy and productive working environment.

The post-holder will participate in any training programme implemented by the organisation as part of this employment, such training to include:

• Participation in an annual individual performance review, including taking responsibility for maintaining a record of own personal and/or professional development
• Taking responsibility for own development, learning and performance and demonstrating skills and activities to others who are undertaking similar work

All employees have a responsibility to participate in regular appraisal with their line manager and to identify performance standards for the post. As part of the appraisal process employees have a joint responsibility with their line manager to identify any learning development needs in order to meet the agreed performance standards.

The post-holder will strive to maintain quality within the organisation, and will:

• Alert other team members to issues of quality and risk
• Assess own performance and take accountability for own actions, either directly or under supervision
• Contribute to the effectiveness of the team by reflecting on own and team activities and making suggestions on ways to improve and enhance the teams performance
• Work effectively with individuals in other agencies to meet service needs
• Effectively manage own time, workload and resources

The post-holder should recognize the importance of effective communication within the team and will strive to:

• Communicate effectively with other team members
• Recognise peoples needs for alternative methods of communication and respond accordingly
• Contribution to the Implementation of Services:

The post-holder will

• Apply organisational policies, standards and guidance
• Discuss with other members of the team how the policies, standards and guidelines will affect own work
• Participate in audit where appropriate

This job description is intended to provide an outline of the key tasks and responsibilities only. There may be other duties required of the post-holder commensurate with the position.

All members of staff should be prepared to take on additional duties or relinquish existing duties to maintain the efficient running of the GP Alliance.

This job description is subject to review and amendment in the light of developing or changing services and as part of the annual Individual Performance Review.

Person Specification

Qualifications

Essential

• Good general level of education with a minimum of GCSE Grade 4 (or equivalent) in English Language and Maths.

Desirable

• Professional Qualification.
• Evidence of continuing professional development.

Personal Attributes

Essential

• A mature approach and a professional and friendly demeanour
• Ability to multi-task and work with an unpredictable work pattern with changing priorities throughout the day.
• Professional telephone manner and good listening skills.
• Professional approach to appearance and conduct
• Ability to work with a wide range of professionals & patients at all levels
• Ability to work flexible hours when required
• Self-motivated, Creative/innovative, pro-active, reliable and a professional attitude
• Ability to work across teams and at all levels of the organisation.

Key Skills

Essential

• Ability to design and deliver compliance training.
• Excellent interpersonal verbal & written communication skills
• Ability to prioritise and manage own workload.
• Effective problem solver
• Ability to extract data from conversation or direct dictation

Desirable

• Knowledge of clinical system (EMIS)
• Good understanding of Access to Medical Records Act.
• Good understanding of the Data Protection Act.

Experience

Essential

• Strong understanding of CQC standards and healthcare regulatory frameworks.
• Experience in compliance management, ideally within a healthcare or GP Federation/Primary Care setting.
• Experience in policy development, audit, governance, and risk management.
• Working knowledge and experience of packages including Word, Excel, EMIS and Outlook
• Awareness and maintenance of confidentiality
• Experience of working as part of a multi-disciplinary team
• Ability to understand and learn new software and administrative procedures
• Identifying training & development needs.

Desirable

• Knowledge of bookkeeping and accounts
• Experience of developing effective processes & procedures
• Previous experience working within Primary Care or NHS setting.
• Experience managing compliance portals such as QCS.
• Knowledge of data protection, safeguarding, and information governance requirements.

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

East Lancashire Alliance

Address

Burnley Business Centre

Empire Way

Burnley

BB12 6HH

Employer's website