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CDC Accreditation Lead

James Paget University Hospitals NHS Foundation Trust
£43,742 to £50,056 a year pa pro rata
Closing date
26 May 2024

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Other Health Profession
Band 7
Contract Type
Full Time
To support the Divisional Governance Lead in quality, governance and safety standards in the Community Diagnostic Centre's service covering both the JPUH site and the Cranbrook CDC at Northgate.

Tomanage and be accountable for:

Improving Quality in Physiological Services (IQIPS).

Quality Standards for Imaging (QSI).

The requirements for quality and competence in a medical laboratory environment (ISO15189).

accreditation processes throughout the CDC, working with the service leads to ensure that accreditation is successfully obtained through the United Kingdom Accreditation Service (UKAS) and thereafter maintained.

To support the Speciality Leads in ensuring high quality audits and governance processes.

To support the delivery of a high quality, safe and compassionate healthcare service, all staff are expected to act as a role model to others in all aspects of their work.

Main duties of the job

The position of Accreditation Lead will be an extremely important role within the CDC and will be supported by the Divisional Operations Manager together with the Matron overseeing the CDCs.

There is an expectation from NHSE that the CDC will be accredited, or towards the end of the accreditation process, within two years of the CDC opening. To achieve this will require a good knowledge of the accreditation process, excellent organisation skills and the ability to work well with the speciality leads.

Work is already being undertaken to support QSI accreditation in imaging and there are staff in radiology who will be able to help support this process.

Both CDCs are due to open at the end of 2024 giving the successful candidate the opportunity to be influential in the setting up of processes and procedures before the CDC opens.

The Trust operates the Q-Pulse document management system.

About us

We want to attract the best and brightest people to work with us and that means we will look after you from the moment you apply for a role at the Trust and throughout your career with us. Our staff are central to everything we do, and we believe that investing in you is crucial if we want to enable you to reach your full potential.

Job description

Job responsibilities

1. To be responsible for leading the CDCs through the accreditation process for the services being provided, working with the accreditation team and service leads, and that the service then maintains accreditation.

2. To complete the web-based electronic assessment process and complete this annually following accreditation.

3. To coordinate the services responses to the United Kingdom Accreditation Service (UKAS), ensuring that all evidence uploaded to the specialities web based assessment is relevant, up-to-date, and fully meets the set criteria.

4. To work closely with the Senior Operations Manager, Clinical Governance Lead Matron and speciality leads, to ensure that governance and safety standards are maintained in line with Trust and UKAS requirements.

5. To work with Speciality Team Leads, the Senior Leadership team and Clinical Leads to coordinate relevant audits and evidence requirements of each standard, promoting a culture of continuous quality improvement within each speciality.

6. To process, review and analyse highly complex information, including statistical data and audit information, to inform and advise on governance standards and processes.

7. To be knowledgeable on the requirements of the individual standards and advise other members of staff as to expectations with regards to standards of practice and evidence.

8. Present audits and governance topics at speciality and other governance meetings.

9. Have overarching accountability for ensuring that all the CDC protocols, policies, guidelines and patient information leaflets are maintained as relevant, current and up to date.

10. To ensure all documentation is benchmarked and in line with national guidelines and best practice evidence, implementing changes to processes and procedures in the CDC.

11. To support Speciality Leads and staff in achievement of action plans and mandatory findings in relation to Trust quality and safety audits, and accreditation mandatory findings.

12. To support the Senior Operations Manager in organising quarterly CDC governance meetings.

13. Support the Senior Operations Manager in managing risk assessments and the risk register.

14. Formulate annual governance reports and regular dashboard reports in conjunction with the Senior Operations Manager.

15. To utilise and analyse complex statistics and reports relevant to accreditation standards.

16. Maintain standards in accordance with accreditation requirements.

17. Work with the Modality Leads and Leadership team to implement quality and service improvements.

18. To work to deadlines and be prepared to work flexibly.

19. To be an authorised signatory for small financial expenditures in relation to resources required for governance and accreditation purposes.

20. To work closely with the Speciality Leads and Operational Managers to ensure appropriate financial resourcing of governance and accreditation activities.

21. To manage the financial budget to support the accreditation requirements.

Person Specification



  • Degree level qualification


  • Studied at Masters level
  • Qualification in one of the modalities aiming for accreditation



  • An excellent knowledge of the accreditation process
  • An understanding of the modalities being accredited



  • Significant experience and understanding of diagnostics in the NHS


  • Previous experience of working with UKAS towards accreditation
  • Previous experience of driving quality improvements in a NHS setting



  • Ability to work across a multi-disciplinary team
  • Ability to lead change

Employer details

Employer name

James Paget University Hospitals NHS Foundation Trust


James Paget University Hospital

Lowestoft Road,


NR31 6LA

Any attachments will be accessible after you click to apply.


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