Mortuary Quality and Audit Lead

The post-holder is accountable to the Mortuary manager To act as lead in quality management for the Mortuary and Post Mortem service. To work autonomously to ensure that all policies and procedures are maintained and comply with regulatory and Trust requirements. To review and update all policies and procedures in line with regulatory updates and agreed review timelines. To produce new policies and procedures that reflect change in practice and assist the manager with effective change management processes. To undertake vertical, horizontal and observation audits, in line with the agreed audit schedule. To work with the manager to develop appropriate audit schedules that cover all aspects of regulatory compliance. To work with the manager and lead on staff competency audits in line with agreed training programs and the RISPH APT qualifications. To report process deviations to the manager and assist with the completion of error logs and CAPA plans. Organising regular Mortuary staff meetings,
planning agenda items and circulating action plans. Representing the Mortuary at quality and clinical governance meetings. To work with the manager to ensure all incidents and near misses are appropriately reported. To investigate incidents and produce reports and action plans; reporting back to the Mortuary manager with timelines and findings. To assist the manager with delivering the Coroners contract for post mortem activity, showing performance against agreed contractual KPIs. To ensure that all Mortuary records are up to date and well maintained. To supervise staff in all aspects of Mortuary work, ensuring compliance with procedures and associated risks. If required assist the team to ensure efficient running of the Post Mortem room and delivery To investigate incidents and produce reports and action plans; reporting back to the Mortuary manager with timelines and findings. To assist the manager with delivering the Coroners contract for post mortem activity, showing performance against
agreed contractual KPIs. To ensure that all Mortuary records are up to date and well maintained. To supervise staff in all aspects of Mortuary work, ensuring compliance with procedures and associated risks. If required assist the team to ensure efficient running of the Post Mortem room and delivery of Post Mortem services and department when staff shortage occurs Audit the cleaning and disinfection of the department in line with the agreed procedures and records. To research and implement new equipment and consumables. To assist the manager and supervise staff ensuring appropriate use of equipment and consumables. To work with the manager to deliver savings targets. Assist the manager with annual reviews of policies and procedures, including all risk and COSHH assessments. To preform monthly health and safety audits. To complete monthly fire audits. To check all first aid equipment is complete and in date, ordering replacements when required. To review and assist with implementation
related to new information relevant to infection control. To be a departmental first aid officer and undertake training in basic life support. Assist the Mortuary manager in the delivery of training to all staff in the Mortuary. To act as a mentor where applicable for trainee APTs To assist the Mortuary manager with updating and delivering training to external personnel such as ward staff, pottering staff and bed managers. To complete annual appraisals with allocated members of the team. To assist in the identification of development and training opportunities for the Mortuary staff. Out of Hours To participate in the On-Call out of Hours service for the Coroner/Hospital. To be available to the Coroner/Hospital should there be a Forensic Post Mortem. To be available whenever possible to answer hospital enquiries and outside family or Police enquires To attend the hospital for Major Incident To attend the mortuary out of normal working hours as
required. To facilitate official police identifications as required. To attend Mortuary to assist in tissue donation services Specific Additional Responsibilities Training To ensure that all Trust and Departmental Protocols are adhered to and updated and reviewed as necessary To maintain and develop skills appropriate to the role by attending appropriate training courses supplied by the Trust, HTA, Tissue Donation, AAPT Use knowledge and experience to enhance post mortem procedures and techniques on all deceased to include high-risk infectious cases via Diploma standard training and other acquired knowledge Participation in the annual PDP process Training of junior personnel in the post mortem processes and all mortuary aspects Health and Safety Responsible in safety supervision and to ensure that safe working practices are followed To ensure that staff conform to the Health & Safety Code of Practice Health and Safety training and awareness of current policy and