Compliance Manager

JOB SUMMARY:

1. Provide a lead in all matters related to auditing and ensuring that the Estates and Facilities Directorate and The Trust’s PFI partners are fully compliant with all statutory and other relevant approved codes of practice such as Health Technical Memoranda (HTMs) and PAM (Premises Assurance Model).

2. Deputise for the General Manager on matters of Estates Compliance and Quality Assurance.

3. Responsible for setting, monitoring and reporting the Estates and Facilities Directorate’s compliance performance with respect to statutory and HTM requirements Trust wide, including PFI contracts.

4. Provide specialist expert Compliance advice and delivering management reports to the Estates and Facilities Directorate.

5. Responsible for the development of a robust system to monitor developments in compliance issues and ensure that regular updates are provided to the team such that the service remains current and up-to-date.

6. Monitoring and reporting, through audit, customer care delivery standards for all Estates and Facilities Directorate work activity across the Trust.

7. Deputise for and undertake the duties of Estates and Facilities Directorate colleagues as requested.

8. To manage delegated staff, consultants and specialist contractors as the duties of the post dictates.

9. Apply sound risk based methodologies to all work undertaken.

10. Responsible for the delivery of quality standards for all compliance work undertaken by the Estates and Facilities Directorate.

11. Contribute to the delivery of compliance standards for all work undertaken by the Estates and Facilities Directorate.

12. Ensure compliance by liaison and discussion.

13. To produce reports from the MiCAD and Planet (CAFM) systems.
14. To manage and operate the Planet (CAFM) system and collate all data for the ERIC submission, on occasion operate the helpdesk in conjunction with colleagues.

MAIN DUTIES AND RESPONSIBILITIES

• To assist the appointed Responsible Person water as defined within L8 in his duties Trustwide.

• To assist in the delivery of ACoP L8 compliance for legionella and the management of Pseudomonas in accordance with all current statutory, HTM and acknowledged guidance.

• To chair and organise the directorate’s compliance meetings.

• To manage, operate, populate (input data) and develop the Estates and Facilities compliance systems e.g. MiCAD, CAFM (Planet), PAM paperwork systems etc.

• To liaise with colleagues to gather the necessary information and assurances of works undertaken to achieve compliance.

• To develop a robust reporting and monitoring strategy to confirm compliance and set standards to be applied across all work which reflect Trust requirements for high quality accommodation and high quality Estate services.

• Provide the specialist Estates Compliance service to the Trust by thoroughly inspecting, auditing, checking and testing Estates maintenance systems to compare against statutory, mandatory and NHS Health Technical Memoranda requirements.

• To deliver a comprehensive Estates and Facilities Directorate information system to demonstrate that compliance is in place, utilising the MiCad and Planet systems.

• By a process of auditing and challenge of Estates maintenance systems identify any gaps in compliance, ensure that any gaps are properly reported and recorded and that appropriate remedial actions are put in place to address the non-compliances in a reasonably timely manner.

• Escalate any non-compliance issues to the Senior Operations Manager as appropriate and work with the Senior Operations Manager and colleagues to resolve.

• Prepare regular detailed reports on Estates Compliance matters and present the information at appropriate meetings and committees.

• Draft and present a regular standardised Compliance Report to the Estates and Facilities Directorate Compliance meeting.

• Participate in the Estates and Facilities Team structure and deputise for colleagues as requested.

• Ensure that all Estates and Facilities Directorate Policies and Procedures are subject to timely formal review and monitor the progress of the updating of these policies and procedures as necessary, recording the revue process.

• Oversee and monitor the progress of delivery of all Action Plans checking that the actions are delivered completely and in a timely manner.

• Manage the Estates Quality Assurance System by checking that the quality checks planned are undertaken correctly and that any corrective action identified is carried out and recorded correctly.

• Responsible for ensuring that there are adequate processes in place to identify and achieve statutory compliance in accordance with the requirements of relevant Health & Safety legislation in the premises, conducting audits and where appropriate toolbox talks.

• Compile and provide complex statistical information regarding the Estates and Facilities Directorate as required.

• Complete the PAM model, organise necessary meetings with other directorates in connection with the Premises Assurance Model.

• To act as the Directorate’s Risk Champion for all risks associated with the activities of the Directorate and ensure the Directorate’s Risk Register is regularly reviewed and updated to reflect action taken to mitigate or eliminate the risks identified.

• Develop and agree maintenance standards with colleagues with particular reference to adherence to legislation and codes of practice. Deliver appropriate training and PowerPoint presentations to staff to enhance knowledge of compliance and system usage.

• Responsible for ensuring that the department’s Emergency Manual is up-to-date and that the department has robust plans and arrangements to deal with major incidents and interruptions to services as part of the departments’ Business Continuity Plan. Liaise with external agencies and the Trust’s Risk Team as required. Review the plan quarterly or when required by developments.

• Represent the Estates Department at relevant forums and meetings to ensure that appropriate standards are applied to all capital developments.

• Attend the Trust’s Health and Safety Management Group and Estates H&S Forum meetings and ensure that any actions agreed are developed and completed in a timely manner.

• Update infrastructure records, commission, undertake and manage audits and surveys as required by the post.

• Generate and analyse management reports from the MiCAD and CAFM (Planet) system. Populate these computerised systems with data and documents.

• Manage the key information systems required for department compliance.

• Update and maintain the department’s Key Performance Indicator matrix to achieve the agreed Trust Board’s reporting frequency, collating all data from PFI partner reports and statistical information.

• To undertake any other reasonable duty commensurate with the role of Compliance Manager that may arise.

• To be an authorised signatory as the post dictates and procure goods and services accordingly to enable compliance.

• To undertake regular checks of PPE safety equipment and undertake work throughout the site, including working at heights, in confined spaces and hazardous areas with the appropriate safety equipment and training.