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Overview
The Care Quality Commission (CQC) is the main regulator of health and social care quality in England. It is currently rebuilding its regulatory model following several reviews that were critical of its approach, and The King’s Fund is working with them to support this work. This is an important signal of CQC’s intention to bring evidence and learning into the development of its new approach.
As part of this partnership, we were asked to do some work focused on what makes care outstanding. This report shares our findings from this research and outlines key principles for outstanding care.
Why we did the research
CQC is the main regulator of health and social care quality in England. In 2023, it introduced several changes to its approach. These included a single assessment framework, a new IT platform and different ways of working. Three major reviews identified significant problems with these changes, and CQC is now rebuilding its regulatory model under new leadership.
The King’s Fund has a research partnership with CQC. As part of this partnership, we were asked to do some work focused on what makes care outstanding.
Providers and inspectors often say it is hard to tell the difference between good care and outstanding care. Our research aimed to develop principles that explain what outstanding care looks like and how it is different from good care.
What we did
Our project had two phases: a review of the literature on outstanding care and interviews with stakeholders to understand what outstanding care looks like, followed by a series of 6 workshops to test and refine the principles for outstanding care.
For the interviews we spoke to CQC staff, staff from provider organisations and experts by experience. Interviews explored what outstanding care looks like, how it differs from good care and how principles could help identify outstanding care.
The workshops included people from different sectors (community services, hospitals, mental health care and adult social care), experts by experience and CQC staff. These workshops tested, revised and refined the principles. We also asked participants how they might use the principles. Finally, we held an engagement workshop with CQC’s policy leads for local authority assessment. This was to share our findings and discuss whether the principles could apply to their work.
What does outstanding care look like?
We found that outstanding care varies across different settings. However, there is broad agreement on its key features.
Person-centred care
For people using services, care feels outstanding when it is tailored to their individual needs and preferences. It recognises their strengths and treats them as a ‘whole person’.
Person-centred care looks different in different settings. For some, continuity of care is most important. Across all sectors, however, our findings highlighted two essential features:
a strong focus on the needs and wishes of the individual
active involvement of people in decisions about their care.
Many stakeholders described this relational approach as key to outstanding care. This was particularly true for experts by experience. They emphasised the importance of staff making genuine connections with the people they care for. They also thought it was about staff being curious about their lives. This means understanding their needs. It also means giving them the power to influence their care, where that is what they want.
Leadership
Our research highlighted the critical role of excellent leadership in delivering outstanding care. CQC has long recognised this link.
Leadership influences care in many ways. The literature and our interviews focused on how leaders shape organisational culture. It also considers how they support staff wellbeing. These in turn affect the quality of care.
Outstanding care happens when staff feel engaged, motivated and empowered to take ownership of their work. This environment encourages innovation and continuous service improvement.
Participants described different leadership styles. A common theme was leadership that is flexible, collaborative and shared – that is, it is not always ‘top-down’.
Equity and inclusion
Outstanding care prioritises equity and makes sure everyone is treated fairly and included. This applies to both people using services and staff. The literature shows that organisations with an inclusive culture usually provide better care. Meanwhile, ignoring diverse needs can lead to poor experiences and outcomes.
Although this came up less often in interviews, some people linked equity and inclusion to person-centred care. They also linked it to creating a welcoming environment and focusing on those with the worst health outcomes.
Learning and improvement
Making learning and improvement part of everyday practice is key to high-quality care. This came up in our interviews and workshops. We heard that outstanding care comes from a commitment to continuous reflection and improvement. This means regularly using data and feedback from staff and people who use services, to spot areas for change and make things better.
This theme is closely linked to leadership. This is emphasised in the literature. It highlights the link between a learning culture and a form of leadership that creates a ‘learning organisation’.
Innovation
Innovation plays a key role in improving care for people who use services. In our interviews and workshops, many people said that innovation is what sets outstanding care apart from good care. They stressed that innovation should be an ongoing process, shaped by staff and user feedback and by looking at outcomes. It is not just about having one clever feature or a new piece of technology.
Innovation works best when combined with continuous learning and inclusive leadership. Together, these help to create an environment where staff feel able to find new and better ways of doing things.
Five principles for outstanding care
Based on our literature review and interviews, we developed five principles for outstanding care. We refined them through stakeholder workshops.
Delivering truly person-centred care: outstanding care is always highly responsive to individuals’ needs, preferences and aspirations, recognising what is important to people who use services, their strengths, cultures and histories.
Embedding a culture of compassionate and inclusive leadership: outstanding care happens when leaders foster an open, psychologically safe, inclusive and values-driven culture that is focused on people who use services and empowers staff.
Prioritising equity and inclusion: Outstanding care happens in an environment that is inclusive, prioritises equity and actively embraces diversity among people who use services and staff.
Continuously integrating learning into practice to drive improvement and innovation: outstanding care happens when a learning mindset is embedded in teams and organisations, with a focus on evolving practice and continuously sharing knowledge.
Having a purposeful approach to making a positive difference for people who use services: Outstanding care comes from a clear and deliberate focus on making a positive difference for people who use services, staff and the wider system and is evidenced in key outcome measures and feedback from people who use services and staff.
More about the project
The King’s Fund has a research partnership with CQC. As part of this partnership, we were asked to do some work focused on what makes care outstanding.
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