Strong and transparent leadership is necessary or every other key question in the CQC framework. The ‘Well-Led’ key question will aim to examine the leadership of an organisation and the culture that it fosters to ensure it is capable of offering consistent, high quality care.
What does ‘Well-Led’ mean?
In the five question framework put together by the Care Quality Commission (CQC) ‘Well-Led’ explores whether a service has the vision, leadership, governance and learning culture that is needed to deliver high quality, person-centred care.
The CQC inspectors will look for evidence that leaders understand their legal duties, set clear strategic direction, model the service’s values and make sure there are robust systems of oversight to keep people safe, and staff supported.
‘Well-Led’ is the driver of continuous improvement, as it recognises that if governance is weak, even the best clinical processes can stall.
How do you make sure your service is ‘Well-Led’?
To ensure that your care service is ‘Well-Led’, you need to define and share your purpose by publishing a realistic vision and set of values that have been developed with the help of staff, the people that use the service and their families. This will help you to build visible, knowledgeable leadership where registered managers and senior clinicians are approachable.
It is also important to embed good governance by using regular audits, incident reviews and performance dashboards to help spot any themes that are occurring and act swiftly in response. You should document any decisions to show the audit trail that led to an improvement.
Promoting open learning cultures is also important as staff need safe spaces where they can speak up, report near misses and share ideas. It is also essential to invest in people by providing structured inductions, ongoing CPD and clear career pathways.
Listening to external voices is also vital, so involve advocates, commissioners and community groups as well as making use of any complaints data and compliments to refine your services. You should always ensure that you stay compliant by keeping your policies current, archive superseded versions, and review the “big three” annually.
‘Well-Led’ quality statements
The quality statements for ‘Well-Led’ include:
- Shared direction and culture
- Capable, compassionate and inclusive leaders
- Freedom to speak up
- Workforce equality, diversity, and inclusion
- Governance, management and sustainability
- Learning improvement and innovation
- Environmental sustainability
What does the CQC look for in the ‘Well-Led’ key question?
CQC inspectors will want to interview leaders to find out how they assure themselves that safeguarding is effective and how they know staff are competent.
They will also want to talk to the staff and check that they feel listened to and are able to confidently describe the values of the organisation. Inspectors will also review governance records such as risk registers, incident logs, audits, action tracked meeting minutes and look for evidence of learning which is shared across different teams.
They will look at the financial side of the organisation and check whether any investment is aligned to the priorities of the setting.
They will also take a sample of real time data to look at sickness rates, agency usage, turnover and mandatory training completion to provide a snapshot of the realities of the setting.
It is important to be able to track an improvement journey, so you should be aiming to show how a complaint or adverse event has led to root cause analysis, a SMART action plan and some sort of measurable change.
The CQC will also check leadership resilience to find out what your contingency is if the registered manager is unexpectedly absent. This will look at any succession plans that are in place and make sure that “acting-up” arrangements are documented.
Need some help?
Here at Delphi Care we have to knowledge and expertise to help your service meet the standards for ‘Outstanding’ care. Our team is made up of former CQC inspectors and ex registered managers, with over 200 collective years’ experience of working in the health and social care sector.
Whether you require our consultancy services, mock inspections, or crisis management and turnaround, we’re here to help! Simply contact us today on 0330 133 3002 or email us at customer-care@delphi.care.
If you would like to chat with one of our consultants, then why not book a meeting now.
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