BHSCT Decontamination Quality,Assurance & Improvement Manager Band 6 ref:56023502
Branch: Belfast HSCT
Location: DECONTAMINATION UNIT
Salary: Band 6 (£38,682 - £46,580)
Contract Type: Permanent

Job Description
POST: Decontamination Quality, Assurance & Improvement Manager
LOCATION: Belfast Health & Social Care Trust
GRADE: Band 6
REPORTS TO: Safety, Quality and Governance Co-ordinator
RESPONSIBLE TO: Assistant Service Manager for Decontamination

JOB SUMMARY/MAIN PURPOSE:
The post holder will provide operational leadership and quality management expertise within Decontamination Services, supporting the delivery of safe, effective, compliant and patient-focused services while performing a full range of decontamination duties, with senior accountability within the department.

The post holder will act as a key link between operational service delivery and the Safety, Quality and Governance Co-ordinator, ensuring that quality, regulatory and governance requirements are effectively implemented and embedded within day-to-day departmental practice. The role will contribute to the maintenance and continuous improvement of the Quality Management System (QMS), support the achievement of regulatory compliance standards and promote a culture of quality improvement, risk awareness and shared learning.

Working autonomously and independently with minimal managerial direction, planning own workload. The post holder will apply specialist decontamination knowledge and professional judgement when reviewing technical data, investigating quality issues and supporting operational decision-making in accordance with current legislation, national guidance and best practice. The post holder will provide day-to-day leadership, management and support to operational teams and deputise for senior managers as required.

Main Duties/Responsibilities

• Support the implementation, maintenance and continuous improvement of the Service Quality Management System (QMS), ensuring compliance with regulatory, statutory and accreditation requirements.
• Co-ordinate the development, review and control of Standard Operating Procedures (SOPs) and quality documentation, ensuring quality records are accurate, current, complete and compliant.
• Support departmental compliance with BS EN ISO 13485: 2016, Medical Devices Regulations, Health Technical Memoranda (HTM), Department of Health Guidance and other applicable standards and guidance.
• Co-ordinate and participate in internal audits, supporting the delivery of an internal audit programme compliant with BS EN ISO 13485:2016, ensuring audits are completed in accordance with agreed schedules and that associated Corrective and Preventive Actions (CAPA) are implemented, monitored and reviewed for effectiveness.
• Support preparation for external assessments and audits, including BSI audits, IHEEM audits and Department of Health assurance requirements.
• Support the investigation of non-conformances, Datix, incidents, complaints and quality concerns, contributing to root cause analysis and the development of corrective and preventative actions.
• Monitor and analyse trends arising from incidents, Datix and internal non-conformances, sharing with all teams and implementing strategies to reduce recurrence and improve compliance.
• Promote and support the shared learning of incidents, Datix and non-conformities, ensuring effective communication and positive engagement with all grades of staff.
• Assist in the preparation of governance reports for divisional governance meetings.
• Collate and present data in support of the delivery of a quality decontamination service for discussion during Senior Management Team meetings.
• Support the development and implementation of service improvement initiatives arising from audit findings, inspections, incidents, Datix, risk assessments and stakeholder feedback.
• Provide advice and guidance to departmental staff on quality management processes, documentation control, audit requirements and compliance with applicable standards.
• Assist with maintaining departmental risk registers and risk assessments, implementing risk control measures, identifying emerging risks and escalating concerns appropriately.
• Support the Safety, Quality and Governance Co-ordinator and Senior Management Team with the delivery, development and oversight of Central and Local Decontamination Assurance requirements; assisting with the creation, maintenance, updating and continuous improvement of assurance programmes and documentation.
• Undertake audits within central and local decontamination areas in accordance with Decontamination Assurance requirements and the BHSCT Integrated Governance and Assurance Framework, providing findings, reports and feedback to local Service Managers and Senior Management colleagues.
• Promote a culture of openness, learning and patient safety.
• Support the day-to-day operational management team of Decontamination Services to ensure the delivery of safe, effective and timely services.
• Monitor service performance, capacity and workflow, ensuring resources are used effectively to meet operational demands.
• Assist in workforce planning, rota co-ordination and service continuity arrangements where required.
• Participate in recruitment, induction, training and ongoing development of staff.
• Act as a role model and promote a culture of professionalism, accountability and continuous improvement.
• Support validation, verification and commissioning activities associated with decontamination equipment and processes.
• Liaise with Estates, equipment manufacturers, Authorising Engineers, Authorised Persons and other specialist stakeholders to ensure compliance with statutory and regulatory requirements.
• Assist with the review of periodic testing, calibration and environmental monitoring programmes, ensuring completion and appropriate documentation.
• To maintain high standards of departmental safety ensuring the Health and Safety of self, other staff and visitors and to inform the departmental senior manager of any issue.
• To participate in Continuous Professional and Personal Development, to keep abreast of advances and developments within the speciality.

Quality Management System

• To work collaboratively with other departmental staff to ensure on-going compliance with accreditation standards, audits, policies and procedures to ensure continuing certification to BS EN ISO 13485:2016.
• In collaboration with the Senior Management Team, perform reviews of the Quality Management system, creating mechanisms in the form of Key Performance Indicators, noting targets and opportunities for improvement.
• Contribute to the Decontamination Assurance process, assisting in the gathering of central decontamination statements, local decontamination statements, collating and updating information and performing audits where required.

Communication

• To attend and actively participate in meetings and support the decontamination operational team as required.
• Develop effective collaborative relationships with internal and external stakeholders.
• Communicate complex technical and quality information clearly and effectively to staff at all levels.
• Prepare reports, presentations and quality performance information for service meetings and governance forums.
• Support communication and engagement activities relating to quality improvement and service development initiatives.
• Maintain good relationships and morale amongst staff throughout the Decontamination Service.

Management

• Supports the management of teams across the Decontamination Service, working in conjunction with the operational management team.
• To participate in the selection, appointment and training of staff.
• Assist the Senior Management Team in the search for innovation and research that will enhance service delivery.
• Assists the Senior Management Team to ensure that a high standard of quality is maintained and continuously improved in line with BS EN ISO 13485: 2016.
• In conjunction with the Senior Management Team, ensure that the Service complies with all regulations and good practice relating to the provision of a quality decontamination service.
• To provide management cover during all opening hours as required across the service.
• Contribute to the development and management of Key Performance Indicators for activities within Decontamination Services.
• Support the management of attendance, performance and conduct matters in accordance with Trust policies.
• To actively participate in the Organisation's appraisal system and personal develop planning process to self and others in accordance with BHSCT Policy.
• Adopt a professional manner at all times.

Information Technology

• To use Trust wide IT systems, as appropriate, adhering to Trust Policies, guidelines and procedures including adherence to Information Governance.
• To adhere to the departments Quality Management System in compliance with ISO 13485: 2016
• Work in partnership with the decontamination services systems administrator to utilise all available technologies in support of the delivery of the decontamination service.
• Utilise internal systems, including the Service's track and trace software and Q-Pulse for Quality management.
• Maintain electronic quality management systems and associated records.
• Analyse and present quality, operational and performance data to support decision making.
• To have full knowledge, experience and be able to train others on the use of all of the department information systems.

Health and Safety

• Adopts a risk management approach in assisting with the oversight with all activities within the decontamination service.
• Assisting with the management of the production of all medical devices including flexible endoscopes to ensure they have been effectively decontaminated through the appropriate processes contributing to the safety and clinical care of the patient.
• In conjunction with the Senior Management Team, review and interpret legislation, standards and guidance relating to the decontamination of reusable invasive medical devices and decontamination equipment, assisting in any changes and subsequent actions that are required to be implemented.
• Identify potential risks and update the Senior Management Team for possible inclusion to the ACCTSS risk register.
• To assist the Senior Management Team to ensure systems of risk management and health and safety monitoring are implemented and that action is taken to deal with identified issues as they arise.
• To ensure there are safe systems of work in place, identifying, where possible, through risk assessment, potential risks and reducing or eliminating any practices that pose a significant risk.
• To ensure staff are aware of the risk assessments in place to protect the health and safety of themselves and others and ensure regular review of the same.

General Responsibilities

• At all times provide a caring service and to treat those with whom they come into contact in a courteous and respectful manner.
• Demonstrate their commitment by their regular attendance and the efficient completion of all tasks allocated to them.
• Comply with the Trust's Smoke Free Policy.
• Carry out their duties and responsibilities in compliance with the Health and Safety Policies and Statutory Regulations.
• Adhere to Equality and Good Relations duties throughout the course of their employment.
• Ensure the ongoing confidence of the public in-service provision.
• Maintain high standards of personal accountability.
• Comply with the HPSS Code of Conduct.

Information Governance
All employees of Belfast Health & Social Care Trust are legally responsible for all records held, created or used as part of their business within the Belfast Health and Social Care Trust, including patient/client, corporate and administrative records whether paper based or electronic and also including e-mails. All such records are public records and are accessible to the general public, with limited exceptions, under the Freedom of Information Act 2000, the Environment Regulations 2004, the General Data Protection Regulation (GDPR) and the Data Protection Act 2018. Employees are required to be conversant and to comply with the Belfast Health and Social Care Trust policies on Information Governance including for example the ICT Security Policy, Data Protection Policy and Records Management Policy and to seek advice if in doubt.

Environmental Cleaning Strategy
The Trusts Environmental Cleaning Strategy recognizes the key principle that “Cleanliness matters is everyone’s responsibility, not just the cleaners” Whilst there are staff employed who are responsible for cleaning services, all Trust staff have a responsibility to ensure a clean, comfortable, safe environment for patients, clients, residents, visitors, staff and members of the general public.

Infection Prevention and Control
The Belfast Trust is committed to reducing Healthcare associated infections (HCAIs) and all staff have a part to play in making this happen. Staff must comply with all policies in relation to Infection Prevention and Control and with ongoing reduction strategies. Standard Infection Prevention and Control Precautions must be used at all times to ensure the safety of patients and staff.

This includes:

• Cleaning hands either with soap and water or a hand sanitiser at the appropriate times (WHO '5 moments');
• Using the correct '7 step' hand hygiene technique;
• Being 'bare below the elbows' when in a clinical environment;
• Following Trust policies and the Regional Infection Control Manual (found on intranet);
• Wearing the correct Personal Protective Equipment (PPE);
• Ensuring correct handling and disposal of waste (including sharps) and laundry;
• Ensuring all medical devices (equipment) are decontaminated appropriately i.e. cleaned, disinfected and/or sterilised;
• Ensuring compliance with High Impact Interventions.

Values
The Belfast Trust aims to recruit staff not only with the right skills but also with the right values to ensure the delivery of excellent patient care and experience. Staff will be expected to be committed to provide safe, effective, compassionate and person centered care by:

• Treating Everyone with Dignity and Respect
• Displaying Openness and Trust
• Being Accountable
• Being Leading Edge
• Maximising Learning and Development

By embedding the above values we will make a significant contribution to the delivery of the Trust's Vision.

Personal Public Involvement
Staff members are expected to involve patients, clients, carers and the wider community were relevant, in developing, planning and delivering our services in a meaningful and effective way, as part of the Trust's ongoing commitment to Personal Public Involvement (PPI).

Please use the link below to access the PPI standards leaflet for further information.

Clause: This job description is not meant to be definitive and may be amended to meet the changing needs of the Belfast Health and Social Care Trust.

Personnel Specification
Essential criteria

• 3 years (band 5 or above) experience in decontamination services OR a University Degree or relevant professional qualification or relevant HNC/HND or equivalent/high qualification AND 2 years' experience (band 5 or above) in decontamination services OR completed HTM 01-01 AND HTM 01-06 user training AND 2 years' experience (band 5 or above) in decontamination services
• Problem solving, department management, relationship management, analysis and research and interpersonal behaviours, including membership of the Institute of Decontamination Sciences (IDSc) or willingness to attain
• Evidence of effective people management, governance and organisational skills; experience of audit, quality improvement, SOPs, incident and non-conformance investigation
• Excellent communication and interpersonal skills; Microsoft Office experience; CPD commitment
• Knowledge of BS EN ISO 13485:2016 and HTM 01-01 and HTM 01-06 + NI addenda

Desirable criteria

• Registration Academy for Healthcare Science Practitioner Register level 6
• Postgraduate degree in medical device decontamination
• Healthcare science practitioner level 6 qualification
• Completed HTM 01-01 AND HTM 01-06 user training

All staff are expected to display the HSC Values at all times