New CQC inspection framework: what does a 'well-led' organisation look like?

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Last week the Care Quality Commission (CQC) launched a consultation giving more detail on proposed changes to the way it regulates, inspects and rates health and social care providers, building on the new vision and direction that it set out last year.

The new inspection framework sets out five ‘domains’, assessing providers on whether they are: safe; effective; caring; responsive to people’s needs; and well-led.

At The King’s Fund, we have been working with the CQC to help them develop their proposals in the one area that is new for the regulator – looking at how well-led an acute trust is. As part of this, the CQC will assess trusts using five key lines of enquiry: the enacted organisational vision and strategy; the governance arrangements; the organisation’s leadership and culture; how providers engage, seek and act on feedback; and the extent to which the provider seeks to continuously learn and improve. Significantly, these five lines of enquiry cover the leadership and culture of a provider, not just their governance arrangements.

It is heartening that CQC has made understanding culture an important part of its new regulatory framework. At the Fund, we are passionate about the role that culture and leadership can play in supporting organisations to deliver high-quality compassionate care for patients. Culture – 'the way we do things around here' – highlights what a provider places value on and is a powerful influence on the behaviour of staff at all levels. Nurturing appropriate cultures means supporting an environment in which openness, candour, honesty and transparency are encouraged.

Leaders in an organisation are key determinants of how the culture within that organisation develops, and for this reason it is crucial that providers are clear about their leadership strategy. This includes making sure they know what leadership capacity and capability is needed now and in the future, and where it needs to be located in their organisation. Proactive development of a leadership strategy by boards can help nurture the kind of organisational culture that is 100 per cent focused on continuous learning and delivering high-quality compassionate care.

Part of this leadership strategy may also include developing collective leadership that supports clinical leaders and managers at all levels, and that works across services and departments to reinforce the values of the organisation. Boards will need to assure themselves that they are clear about the values that drive them and the leaders in their organisation, and that these values are shared, with a focus on quality, compassion and candour.

Although the focus on culture and leadership is very welcome, boards may find being inspected on these criteria challenging. In our work with the CQC, we have been encouraged by its new way of approaching the inspection process. The new model intends to be less about inspectors coming into an organisation solely focused on box-ticking and developing ratings and more about getting under the skin of the culture and leadership of an organisation to share key learning from the inspection with the organisation– it’s more of a peer review.

It is also encouraging that CQC’s new model of inspections proposes to learn from an ‘appreciative inquiry’ approach, which uses support and challenge to develop learning organisations, and which builds on the successes, not the negatives. Our experience highlights the importance of this type of peer review approach that supports and challenges in order to develop learning organisations. We’re currently working with providers in one region to train staff from acute trusts to form a network of peer reviewers who can use the CQC assessment framework to drive continuous improvement and quality.

As The King’s Fund has argued before, regulators cannot alone ensure quality, and can only ever be the third line of defence against poor care - the first line of defence being frontline staff, and the second being the leaders and boards of organisations.

The consultation documents published last week signal the key areas of focus for the regulators, so providers can start gearing up for inspections now – they don’t need to wait until CQC comes knocking.



Comment date
24 April 2014

Jonathan Fielden

Medical director,
Comment date
26 April 2014
First line of defence is patients - thus the vital need for (as close to) real time feedback, good and bad. Plus to really listen and act with patients
Second line is frontline workers
Third the exec and board
Fourth we must remember commissioners , by focussing on outcomes and the important impact of leadership and culture in achieving these commissioners fundamentally impact on quality.
Regulation comes a (?distant) 5th in that it has an intermittent and often reactive impact.
Day to day it is working with and listening close to patients (and carers) and frontline staff that we can drive continuous improvements in quality.

Stavroulla Ng

Comment date
21 September 2014
Re: Persons with learning disabilities, autism and can challenge:

I totally agree with Jonathan Fielden's comments and welcome the expert academic focus on CQC inspection on organisation culture in hospitals but I need to stress that for too long the LD / ASD services have been ignored and people are dying and harmed needlessly, it is currently in a very dangerous place.
The organisation behaviour of NHS providers & so-called "too large to fail" types have become complacent and powerful because processes such as Complaints procedures, Safe-Guarding, have no "teeth" or sanctions without which you will not be able to change behaviour.

Similarly, the excellent "recommendations and guidelines" in the recently published "NICE Guidelines on Autism" will need to be changed from weasel words like Recommendations to Requirements and appropriate sanctions applied to those who have the responsibility and therefore should be accountable when serious incidents leading to harm and death to persons occur. Those persons directly responsible as well as the organisation culture that encourages should become liable under civil & criminal law.
Presently, these changes are moving too slowly to save and help many adults, children and families in distress and jeopardy.

David burbidge

Local Healthwatch
Comment date
20 August 2015
I agree with Jonathan Fielden's comments but I also recognise that when the culture is one of bullying of staff it is important to understand that this repeats on to Patients , I have seen and heard of some horrific cases were patient reps have virtually been shouted down when they either complain or speak up to right wrongs or persuaded to withdraw form the fight , and that is just what it has become

Pearl Baker

Independent Mental Health Advocate and Advisor,
Comment date
29 September 2015
I have just studied the latest CQC 2015 'new style inspection of GPs' 4-6 weeks to go- CQC meet with CCG and Local NHS Team.
2 weeks to go CQC confirm your inspection and request information such as your statement of purpose and information on complaints, or serious or adverse incidents?

My concerns are the majority of CCG Board members are GPs NOT Managers, they are ill equipped in their understanding of current LAWS and Legislation surrounding Section 117 of the 1983 MHA MCA or indeed the Care Act.

My meeting with a GP Practice confirmed they have been informed to discharge severely mentally ill from Care Plans if they have not been in hospital for a while, they also confirmed they DO NOT have a COPY OF THE CARE ACT 2014.

The Question is where is 'integration' and who gave instructions to discharge LTC from Care Plans, was it the CCG or the LA, either way there are still serious issues in the latest CQC GP Inspection process.

John Morris

Retired user
Comment date
07 January 2020

The CQC have been the only organisation that have listened to the neglect i have found with the new executive team now running my hospital i agree with Johnathan Feildens comments my only worry is the level of inspection that can be done to make sure that the CEO who controls everything is dealing with patients in communicating with them and not just giving his own views of what is happening i.e on their website he praises the fact that they have done 404 operation out of 404 i have waited 2 years so to get the hospital caring with staff caring the top person has to get a complete investigation from Patients, staff, and department leaders


Social care client,
Comment date
27 January 2020

I have disabilities and employ private Care Agencies. I have tried several Agencies and there have been serious issues with all of them. The support cover is inadequate. It can take months to be allocated a carer and then when they take holiday, are off sick, or have training days, I am left without care cover. I cannot get random care cover, so cannot attend events that I would like to, and have missed hospital appointments due to carers arriving late. The carers are unable to do what I need them to do. I am taken advantage of by some carers. My safety has been put at risk at times. I am ignored, undermined and dis-empowered. Although I have a Personal Budget, I am at risk of losing it if it continues to be under used because of poor care provision by Care Agencies. If I report issues, I am at risk of having support withheld, or worse still, being told that I am not a suitable client for the Agency. This is the downside of needing care support, and I don't see it improving any time soon!

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