JOB DESCRIPTION

Job Title: Clinical Lead / Clinical Auditor
Location: Croydon, South London
Service Type: CQC-Regulated Mental Health Residential Care
Reports To: Director
Responsible For: Clinical quality, care standards, clinical governance, auditing and practice development
Hours: Full-Time / Part-Time – To Be Confirmed
Salary: As detailed in Advert
Contract: Permanent / Fixed Term

JOB PURPOSE

The Clinical Lead / Clinical Auditor will provide professional clinical leadership, oversight and quality assurance across the organisation's mental health residential care services.

The post holder will work closely with Registered Managers, senior staff and support workers to ensure that residents receive safe, effective, person-centred and evidence-informed care that promotes recovery, independence, dignity, choice and wellbeing.

The role combines clinical leadership with independent quality auditing, providing assurance that care planning, risk management, medication practices, safeguarding, incident management, record keeping and staff practice meet organisational policies, regulatory requirements and recognised standards of good practice.

The Clinical Lead / Clinical Auditor will identify areas of good practice, areas requiring improvement and potential risks, and will work with management teams to develop and monitor appropriate action plans.

KEY RESPONSIBILITIES:

Clinical Leadership:

Provide clinical leadership and professional guidance to Registered Managers and care teams.
Promote a recovery-focused, person-centred approach to supporting adults with mental health needs.
Provide advice regarding complex presentations, changing needs and emerging clinical risks.
Support staff to understand and implement individualised care plans and risk management plans.
Promote dignity, privacy, choice, independence and positive risk-taking.
Ensure care is delivered in accordance with residents' assessed needs and agreed outcomes.
Provide guidance regarding escalation where a resident's mental or physical health deteriorates.
Support effective communication with GPs, community mental health teams, psychiatrists, social workers, care coordinators and other relevant professionals.
Review whether residents are receiving appropriate professional input and whether recommendations from external professionals are being implemented.
Support managers with clinical decision-making within the boundaries of the role and professional competence.
Escalate concerns where residents' needs exceed the service's ability to safely meet them.

CLINICAL AUDITING AND QUALITY ASSURANCE:

The post holder will undertake a structured programme of clinical and quality audits across the organisation.

Audits may include:

Care Planning:

Initial assessments and pre-admission information.
Person-centred care plans.
Recovery and outcome-focused plans.
Reviews of care plans following changes in presentation or circumstances.
Evidence that residents' choices, preferences and goals are reflected in their care.
Evidence of resident involvement in care planning.

Risk Management:

Risk assessments and risk management plans.
Mental health relapse indicators.
Self-harm and suicide risk where applicable.
Absconding/missing-person risks.
Violence and aggression.
Exploitation and vulnerability.
Substance misuse.
Environmental and community risks.
Positive risk-taking arrangements.
Evidence that identified risks are reviewed following incidents or changes in circumstances.

Medication Management:

Medication administration records.
Medication reviews.
PRN medication protocols and effectiveness reviews.
Medication errors and incidents.
Controlled drugs, where applicable.
Storage and security of medicines.
Medication competency assessments.
Evidence of appropriate escalation of medication concerns.
Audit of medication-related incidents and trends.

Mental Health Monitoring:

Evidence of monitoring changes in mental state.
Mental health reviews.
Physical health monitoring.
Professional appointments and recommendations.
Hospital discharge information.
Crisis plans and relapse prevention plans.
Evidence of appropriate escalation when residents' presentation changes.

Incident Management:

Review incident records.
Identify recurring incidents and emerging trends.
Review whether appropriate action was taken following incidents.
Ensure post-incident reviews are completed.
Assess whether care plans and risk assessments were updated following significant incidents.
Identify opportunities for learning and service improvement.

Safeguarding:

Audit safeguarding concerns and referrals.
Review whether safeguarding procedures have been followed.
Check appropriate escalation to management and external agencies.
Identify safeguarding themes and trends.
Ensure lessons learned are incorporated into practice.

Record Keeping:

Audit daily notes and progress records.
Review accuracy, relevance and professional quality of documentation.
Ensure records demonstrate the support provided and residents' responses.
Identify poor, inconsistent or retrospective recording.
Promote accurate, contemporaneous and objective documentation.

CQC AND REGULATORY COMPLIANCE:

The Clinical Lead / Clinical Auditor will support the organisation in maintaining compliance with relevant CQC requirements and applicable legislation.

The post holder will contribute to assurance relating to:

Safe care and treatment.
Safeguarding.
Person-centred care.
Dignity and respect.
Good governance.
Staffing and competency.
Risk management.
Medication management.
Incident management.
Duty of candour, where applicable.
Mental Capacity Act requirements.
Deprivation of Liberty Safeguards, where applicable.
Mental Health Act requirements where relevant to the service.
Equality, diversity and human rights.
Data protection and confidentiality.
Health and safety.

The post holder will maintain an awareness of relevant changes to legislation, guidance and professional standards and advise management accordingly.

CLINICAL GOVERNANCE:

The Clinical Lead / Clinical Auditor will contribute to the development of a robust clinical governance framework.

Responsibilities include:

Maintaining a programme of scheduled clinical audits.
Producing monthly and quarterly clinical audit reports.
Identifying areas of non-compliance.
Producing recommendations for improvement.
Developing and monitoring action plans.
Tracking outstanding actions to completion.
Identifying recurring failures and systemic issues.
Reporting significant risks to senior management.
Supporting managers to demonstrate evidence of continuous improvement.
Identifying themes across services and using these to inform organisational learning.

The post holder should maintain an audit trail demonstrating that identified concerns have been acted upon and reviewed for effectiveness.

STAFF DEVELOPMENT AND COMPETENCY:

The Clinical Lead / Clinical Auditor will support the organisation's approach to staff development and competency.

This may include:

Identifying training needs through audit findings.
Providing clinical guidance and coaching.
Supporting induction and competency assessment.
Reviewing staff understanding of care plans and risk management.
Supporting reflective practice.
Providing feedback following audits.
Identifying areas where additional supervision may be required.
Supporting managers to develop staff competency.
Contributing to clinical and care-related training sessions.

Where appropriate, the post holder may participate in competency assessments relating to areas such as medication, documentation, safeguarding, mental health awareness and risk management.

RESIDENT INVOLVEMENT AND RECOVER:

The post holder will promote a recovery-focused approach to care.

This includes ensuring that:

Residents are involved in decisions about their care.
Residents' views and preferences are recorded.
Individual goals and outcomes are meaningful and regularly reviewed.
Residents are supported to maintain independence.
Residents are encouraged to participate in community activities.
Residents' strengths and abilities are recognised.
Positive risk-taking is considered appropriately.
Residents' dignity, privacy and human rights are respected.

The post holder should ensure that audits assess not only whether documentation exists, but whether records demonstrate meaningful, person-centred practice.

PROFESSIONAL COLLABORATION:

The Clinical Lead / Clinical Auditor will develop effective working relationships with:

Registered Managers.
Regional Managers.
Support Workers.
Senior Support Workers.
GPs.
Community Mental Health Teams.
Psychiatrists.
Care Coordinators.
Social Workers.
Occupational Therapists.
Community nurses.
Pharmacists.
Local authority professionals.
CQC and other regulatory bodies where required.
Residents, families and advocates.

The post holder will ensure that relevant clinical information is appropriately communicated and escalated.

AUDIT REPORTING:

Following each audit, the Clinical Lead / Clinical Auditor should produce a clear report identifying:

Areas of compliance.
Good practice identified.
Areas requiring improvement.
Level of risk identified.
Required corrective actions.
Person responsible for each action.
Target completion date.
Evidence required to demonstrate completion.
Follow-up audit date.
Whether the action has been effectively completed.

Where significant risks are identified, these must be escalated immediately rather than waiting for the scheduled audit report.

INCIDENT AND THEMATIC ANALYSIS:

The post holder will review service data to identify trends and recurring concerns.

This may include analysis of:

Falls.
Medication errors.
Safeguarding incidents.
Behavioural incidents.
Hospital admissions.
A&E attendances.
Missing-person incidents.
Self-harm incidents.
Complaints.
Restrictive practices, where applicable.
Mental health deterioration.
Staff-related incidents.
Care-plan failures.
Missed appointments.
Failure to follow professional recommendations.

The Clinical Lead / Clinical Auditor will make recommendations where trends indicate that changes to practice, training, staffing or care planning may be required.

QUALITY IMPROVEMENT:

The post holder will contribute to a culture of continuous improvement by:

Identifying opportunities to improve resident outcomes.
Sharing good practice between services.
Supporting implementation of improvement plans.
Monitoring whether changes have produced measurable improvements.
Reviewing policies and procedures from a clinical perspective.
Supporting managers with preparation for regulatory inspections.
Ensuring evidence of improvement is retained and readily accessible.

PROFESSIONAL STANDARDS AND CONFIDENTIALITY:

The post holder must:

Maintain professional boundaries.
Maintain confidentiality at all times.
Comply with UK GDPR and data protection requirements.
Maintain accurate and professional records.
Work within their professional scope of practice.
Escalate concerns appropriately.
Maintain professional registration where registration is a requirement of the post.
Maintain continuing professional development.
Declare any conflicts of interest.
Comply with organisational policies and procedures.

ESSENTIAL QUALIFICATIONS AND EXPERIENCE:

The successful candidate should have:

A relevant clinical or healthcare qualification.
Current professional registration where applicable to their professional role.
Significant experience working within mental health services.
Experience working with adults with complex mental health needs.
Experience of clinical or care auditing.
Knowledge of CQC-regulated services.
Good understanding of safeguarding.
Good understanding of risk assessment and risk management.
Knowledge of person-centred and recovery-focused care.
Knowledge of the Mental Capacity Act and associated principles.
Understanding of medication management and clinical governance.
Experience reviewing care plans and clinical documentation.
Excellent written and verbal communication skills.
Ability to analyse information and identify themes and risks.
Ability to produce professional audit reports.

DESIRABLE QUALIFICATIONS AND EXPERIENCE:

Desirable experience may include:

Registered Mental Health Nurse (RMN).
Registered Nurse (Mental Health).
Occupational Therapist.
Social Worker or other appropriately qualified healthcare professional.
Clinical audit or quality assurance qualification.
Experience working within residential mental health services.
Experience working with CQC inspection frameworks.
Experience of service improvement.
Experience of staff training and competency assessment.
Experience of incident investigation.
Experience of safeguarding investigations.
Knowledge of NICE guidance and evidence-based practice.

PERSONAL ATTRIBUTES:

The successful candidate should be:

Professional and approachable.
Clinically confident.
Analytical and methodical.
Compassionate and resident-focused.
Honest and able to challenge poor practice constructively.
Organised and able to manage competing priorities.
Confident communicating with senior managers and frontline staff.
Able to work independently.
Able to maintain professional objectivity when undertaking audits.
Committed to continuous improvement.
Resilient when dealing with complex situations.
Able to maintain confidentiality and professional integrity.

KEY PERFORMANCE INDICATORS:

Performance may be measured against:

Completion of the annual clinical audit programme.
Timely production of audit reports.
Reduction in recurring clinical and care-related concerns.
Completion of corrective action plans.
Improvement in care-plan quality.
Improvement in risk assessment and management.
Medication compliance.
Safeguarding compliance.
Incident reporting and learning.
Staff competency and training compliance.
Evidence of resident involvement.
Evidence of continuous improvement.
Positive outcomes from internal and external inspections.

INDEPENDENCE AND PROFESSIONAL CHALLENGE:

An important part of this role is the ability to provide objective clinical assurance.

The Clinical Lead / Clinical Auditor must be willing to identify and professionally challenge:

Poor practice.
Incomplete or inaccurate records.
Inadequate risk assessments.
Failure to follow care plans.
Failure to act on professional recommendations.
Medication management concerns.
Safeguarding concerns.
Repeated incidents.
Failure to implement previous audit actions.
Practice that may place residents at unnecessary risk.

Concerns must be escalated through the appropriate management and safeguarding channels.

EQUALITY, DIVERSITY AND HUMAN RIGHTS:

The post holder is expected to promote equality, diversity, inclusion and human rights throughout the service.

They must ensure that residents are treated fairly and with dignity, regardless of age, disability, gender, race, culture, sexual orientation, religion or belief, or any other protected characteristic.

HEALTH AND SAFETY:

The post holder must comply with organisational health and safety procedures and report any identified risks promptly.

Where clinical or environmental risks are identified during an audit, the Clinical Lead / Clinical Auditor must ensure these are appropriately recorded and escalated.

SAFEGUARDING:

The Clinical Lead / Clinical Auditor has a responsibility to safeguard residents from abuse, neglect, exploitation and avoidable harm.

The post holder must:

Recognise safeguarding concerns.
Follow organisational safeguarding procedures.
Escalate concerns without delay.
Support appropriate referrals to statutory agencies.
Ensure safeguarding concerns are appropriately documented.
Review whether safeguarding actions have been implemented.
Promote a safeguarding culture throughout the service.

GENERAL RESPONSIBILITIES:

This job description is intended to provide a framework for the role and is not exhaustive.
The post holder may be required to undertake additional duties that are reasonably consistent with the responsibilities and seniority of the position.
The organisation reserves the right to review and amend the job description in response to changes in legislation, regulation, service requirements or organisational structure.
The post holder must at all times work within their professional competence, relevant legislation, professional standards and organisational policies.

PERSON SPECIFICATION:

Requirement

Essential

Desirable

Relevant clinical/healthcare qualification.
Professional registration where applicable.
Mental health experience.
Adult mental health experience.
Clinical auditing experience.
Care-plan auditing.
Risk assessment experience.
Safeguarding knowledge.
Medication governance knowledge.
CQC knowledge.
Mental Capacity Act knowledge.
Clinical governance experience.
Incident investigation experience.
Quality improvement experience.
Staff training experience.
NICE/evidence-based practice knowledge.
Experience within residential care.
RMN qualification.

ROLE OBJECTIVE

To provide strong clinical leadership, independent clinical auditing and quality assurance across the organisation, ensuring that residents receive safe, person-centred, recovery-focused care and that the service maintains high standards of clinical governance, regulatory compliance and continuous improvement.

Christ The King Residential Care Homes

Clinical Lead

About the Job