This is a senior post within the Trust with a wide range of responsibilities. This is a
challenging role with a high level of complexity as the role requires the post holder to
provide clinical and organisational leadership for Ligature management. The post
holder will ensure the Trust meets National Best Practice Standards (including safety
alerts) and will drive forward a clinically lead ligature framework in EPUT.
The postholder is responsible for the Ligature Policy, Procedure and Strategy
management in the Trust, including development, review, monitoring and
The postholder will be responsible for ensuring that all Mental Health locations
remain compliant with the CQC Registration Standards.
The post holder will be required to provide cross cover with other Clinical Leads for
Compliance and cover other Trust services as directed by the Head of Compliance &
The post holder will be responsible for setting the Ligature standards and strategy
within EPUT in line with national best practice. This will be an ongoing and
dynamic process taking into account the continued national and local learning and
ensuring Trust processes can respond to changes needed in a timely way.
2. The post holder will be responsible for the development and ongoing review of the
Ligature Risk Assessment and Management Policy and Procedure ensuring this
is in line with national best practice standards, CQC requirements and takes into
account safety alert learning.
3. The post hold will be responsible for leading on the auditing and monitoring of
compliance with the Ligature policy and procedure.
4. The post holder will be responsible for the development of Ligature inspection
tools and processes in line with national best practice standards. This will involve
working in partnership with the H&S team who undertake the inspections.
5. The post holder will be responsible for ensuring that the annual calendar of
Ligature inspections is in place and implemented. This will be in partnership with
H&S Team, operational services and Estates.
6. The post holder will be responsible for ensuring all actions identified at a Ligature
inspection are completed. This will involve regular reporting on progress to key
Trust committees including the Trust Board of Directors.
7. The post holder will be responsible for setting ligature training at appropriate
levels for all staff including Face to Face and ELearning and bespoke training for
8. The post holder will be responsible for undertaking an annual review of ligature
training including effectiveness of the training and updating when there are
changes to policy/national guidance.
9. The post holder will be responsible for monitoring trends/themes of fixed point
and non-fixed point ligature incidents within the Trust. The post holder will be
responsible for development of a monthly report analysing trends and themes and
presenting findings to appropriate Trust committees.
10. The post holder will be responsible for facilitating the development and collection
of evidence for external Trust inspections including DOH inspections, peer
reviews, CQC inspections. This will require collection and communication of
highly complex and often sensitive information in situations which will require
diplomacy and tact and will require decisions to be made on behalf of and in the
best interest of the Trust.
11. The post holder will be responsible for undertaking internal inspections of the
Trust against CQC ligature standards. This will involve developing audit tools that
meet CQC standards and measure compliance both a ward level and at board
level. The post hold will be responsible for setting the internal programme of
auditing and reporting on and communicating findings from audits back to Trust
Board. The post holder will be responsible for developing and monitoring action
plan implementation following audit findings
12. The post holder will be responsible for undertaking internal inspections of Trust
mental health services and teams against CQC registration requirements.
13. The post holder will be responsible for identification and analysis of information
intelligence sources which provide assurance of compliance or indications of risk
of non-compliance with Ligature policy and CQC Registration requirements and
escalating findings to appropriate Trust committee.
14. The post holder will be responsible for the developed of robust reports and action
plans for the Ligature Risk Reduction Group, Health Safety and Security
Committee, Quality Committee, Executive Safety Oversight Group and the Board
of Directors. The post holder will appropriately address any areas of non-
compliance and inform the Head of Compliance & Emergency Planning of any
gaps in compliance immediately.
15. Responsible for review of all audits and monitoring undertaken across the Trust
that consider any aspects of Trust policy/ procedure, clinical guidelines or strategy
implementation and for ensuring that this information is built into the compliance
16. Responsible for monitoring and reviewing the risk management ligature project
plan, linking in with Risk Registers ensuring progress with BAF10 and ongoing
development, implementation and monitoring of the Trust policy/ procedure and
strategies ensuring these are reviewed as appropriate and are in date.
17. Responsible for ensuring that learning from all ligature incidents are incorporated
into policy and procedure along with national best practice and legislative
requirements. This will include the post holder being responsible for working with
policy leads at all levels of the organisation to update policies and procedures
according to best practice.
18. To be the central point for all ligature related work and responsible for advising
staff in clinical areas on how policy and procedure should be interpreted in line
with best practice and following audit/monitoring findings.
19. Responsible for developing a system of assurance that will provide assurance to
the Trust Board of Directors of compliance with Trust policies/ procedures, clinical
guidelines and strategies across the Trust.
20. Responsible for the design, implementation and management of a ligature
dashboard system that monitors compliance throughout the Trust in line with
21. Responsible for ensuring identification, monitoring and evaluation of Datix actions
arrangements and escalation where required.
22. Responsible for ensuring that records are kept of all Trust monitoring of
policies/procedures, clinical guidelines and strategies, and are available in the
event of a Corporate Manslaughter claim or a negligence claim against the Trust.
23. Will be required to use clinical judgement and responsible for providing
professional clinical guidance to staff, when determining ligature requirements
across the Trust and for leading on supporting, coaching and training clinical staff
on site visits.
24. Be involved as required in response meetings to identify hot spots and where
required lead/participate in fixed point ligature related incident investigations
Community Mental Health Services