Clinical Lead

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

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