Well-led characteristics – Therapeia: Quality Assured

Below is a summary description of how the CQC would characterise an ‘outstanding’ service from the point of view of being well-led and managed.

For a detailed description of the characteristics of an ‘outstanding’ service please click here

There are key characteristics that make leadership of the service exceptional and distinctive. The leadership, governance and culture are used to drive and improve high- quality, person-centred care.
The service has a strategy and supporting objectives that are stretching and challenging, but realistic and achievable. Staff are strongly collaborative and are motivated by, and proud of, the service.
Governance is well-embedded into the running of the service. Performance management processes are effective, reviewed regularly, and reflect best practice. Leaders and managers provide feedback to staff and there is clear evidence that this leads to improvement.
There are consistently high levels of constructive engagement with staff and people who use services, including all equality groups. Rigorous and constructive challenge from people who use services, the public and stakeholders is welcomed and seen as a vital way of holding services to account.
There is a particularly strong emphasis on continuous improvement. The views of people using the service are at the core of quality monitoring and assurance arrangements. Innovation is celebrated and shared.
The service has a systematic approach to working with other organisations to improve care outcomes.

wdt_ID	Domain	QS Theme	Quality Statement	KLOE equivalent
1	Effective	E: Assessing needs	We maximise the effectiveness of people’s care and treatment by assessing and reviewing their health, care, wellbeing and communication needs with them.	E1
2	Well-led	W: Capable, compassionate and inclusive leaders	We have inclusive leaders at all levels who understand the context in which we deliver care, treatment and support and embody the culture and values of their workforce and organisation. They have the skills, knowledge, experience and credibility to lead effectively. They do so with integrity, openness and honesty.	W1
3	Responsive	R: Care provision, integration and continuity	We understand the diverse health and care needs of people and our local communities, so care is joined-up, flexible and supports choice and continuity.	E4
4	Effective	E: Consent to care and treatment	We tell people about their rights around consent and respect these when we deliver person-centred care and treatment.	E7
5	Effective	E: Delivering evidence-based care and treatment	We plan and deliver people’s care and treatment with them, including what is important and matters to them. We do this in line with legislation and current evidence-based good practice and standards.	E1
6	Well-led	W: Environmental sustainability - sustainable development	We understand any negative impact of our activities on the environment and we strive to make a positive contribution in reducing it and support people to do the same.	No equivalent
7	Responsive	R: Equity in access	We make sure that everyone can access the care, support and treatment they need when they need it.	R1
8	Responsive	R: Equity in experiences and outcomes	We actively seek out and listen to information about people who are most likely to experience inequality in experience or outcomes. We tailor the care, support and treatment in response to this.	R1
9	Well-led	W: Freedom to speak up	We foster a positive culture where people feel that they can speak up and that their voice will be heard.	W3, R2
10	Well-led	W: Governance, management and sustainability	We have clear responsibilities, roles, systems of accountability and good governance. We use these to manage and deliver good quality, sustainable care, treatment and support. We act on the best information about risk, performance and outcomes, and we share this securely with others when appropriate.	W4, W2
11	Effective	E: How staff, teams and services work together	We work effectively across teams and services to support people. We make sure they only need to tell their story once by sharing their assessment of needs when they move between different services.	E4
12	Caring	C: Independence, choice and control	We promote people’s independence, so they know their rights and have choice and control over their own care, treatment and wellbeing.	C3
13	Safe	S: Infection prevention and control	We assess and manage the risk of infection. We detect and control the risk of it spreading and share any concerns with appropriate agencies promptly.	S5
14	Safe	S: Involving people to manage risks	We work with people to understand and manage risks by thinking holistically so that care meets their needs in a way that is safe and supportive and enables them to do the things that matter to them.	S2
15	Caring	C: Kindness, compassion and dignity	We always treat people with kindness, empathy and compassion and we respect their privacy and dignity. We treat colleagues from other organisations with kindness and respect.	C1
16	Safe	S: Learning culture	We have a proactive and positive culture of safety based on openness and honesty, in which concerns about safety are listened to, safety events are investigated and reported thoroughly, and lessons are learned to continually identify and embed good practices.	S6
17	Well-led	W: Learning, improvement and innovation	We focus on continuous learning, innovation and improvement across our organisation and the local system. We encourage creative ways of delivering equality of experience, outcome and quality of life for people. We actively contribute to safe, effective practice and research.	W4
18	Responsive	R: Listening to and involving people	We make it easy for people to share feedback and ideas or raise complaints about their care, treatment and support. We involve them in decisions about their care and tell them what’s changed as a result.	R2
19	Safe	S: Medicines optimisation	We make sure that medicines and treatments are safe and meet people’s needs, capacities and preferences by enabling them to be involved in planning, including when changes happen.	S4
20	Effective	E: Monitoring and improving outcomes	We routinely monitor people’s care and treatment to continuously improve it. We ensure that outcomes are positive and consistent, and that they meet both clinical expectations and the expectations of people themselves.	W4
21	Well-led	W: Partnership and communities	We understand our duty to collaborate and work in partnership, so our services work seamlessly for people. We share information and learning with partners and collaborate for improvement.	W5
22	Responsive	R: Person-centred care	We make sure people are at the centre of their care and treatment choices and we decide, in partnership with them, how to respond to any relevant changes in their needs.	R1
23	Responsive	R: Planning for the future	We support people to plan for important life changes, so they can have enough time to make informed decisions about their future, including at the end of their life.	R3, E4
24	Responsive	R: Providing information	We provide appropriate, accurate and up-to-date information in formats that we tailor to individual needs.	R1, C2
25	Caring	C: Responding to people's immediate needs	We listen to and understand people’s needs, views and wishes. We respond to these in that moment and will act to minimise any discomfort, concern or distress.	C3, C1
26	Safe	S: Safe and effective staffing	We make sure there are enough qualified, skilled and experienced people, who receive effective support, supervision and development. They work together effectively to provide safe care that meets people’s individual needs.	S3
27	Safe	S: Safe environments	We detect and control potential risks in the care environment. We make sure that the equipment, facilities and technology support the delivery of safe care.	S2
28	Safe	S: Safe systems, pathways and transitions	We work with people and our partners to establish and maintain safe systems of care, in which safety is managed, monitored and assured. We ensure continuity of care, including when people move between different services.	E4
29	Safe	S: Safeguarding	We work with people to understand what being safe means to them as well as with our partners on the best way to achieve this. We concentrate on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. We make sure we share concerns quickly and appropriately.	S1
30	Well-led	W: Shared direction and culture	We have a shared vision, strategy and culture. This is based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and our communities in order to meet these.	W1
31	Effective	E: Supporting people to live healthier lives	We support people to manage their health and wellbeing so they can maximise their independence, choice and control. We support them to live healthier lives and where possible, reduce their future needs for care and support.	E5
32	Caring	C: Treating people as individuals	We treat people as individuals and make sure their care, support and treatment meets their needs and preferences. We take account of their strengths, abilities, aspirations, culture and unique backgrounds and protected characteristics.	C1
33	Well-led	W: Workforce equality, diversity and inclusion	We value diversity in our workforce. We work towards an inclusive and fair culture by improving equality and equity for people who work for us.	W1
34	Caring	C: Workforce wellbeing and enablement	We care about and promote the wellbeing of our staff, and we support and enable them to always deliver person centred care.	C2

wdt_ID	Domain	QS Theme	Evidence category	Evidence description	Evidence location	Notes/issues to follow-up
1	Effective	E: Assessing needs	People's experience of health and care services	Results of latest service user satisfaction survey show that 75% of people thought their needs were being properly assessed and reviewed on a continuous basis.	QA folder on server	Need to address the fact that 25% of people surveyed were NOT satisfied.
2	Well-led	W: Capable, compassionate and inclusive leaders	Feedback from staff and leaders	Results of staff focus group run by external consultancy in May 2022 showed that around 50% of members felt their managers were effective leaders and valued their staff team. The other half were far more critical and felt that their views were being ignored and that the managers were only interested in the profitability of the business.	In QA folder on the server.	Need to address as a matter of urgency concerns relating to manager's attidudes regarding valuing all staff memebers' views and their attitude towards the service.
3	Effective	E: Consent to care and treatment	Processes	Care plans show that where appropriate best interest meetings were held where service users lacked consent to care and treatment.	Care plan folder on server
4	Well-led	W: Freedom to speak up	People's experience of health and care services	Analysis of deputy manager's notes from regular telephone calls with service users showed that people felt able to raise concerns about the service and that such concerns were acted upon in a timely manner.	QA folder on server.
5	Safe	S: Safeguarding	Processes	The service has a robust safeguarding policy which includes sections on defintions of abuse, recognising abuse, reporting abuse, and supporting service users in the aftermath of safeguarding incidents	Safeguarding folder on server.	The policy was last updated in July 2018. Needs to be reviewed and updated as necessary.
6	Caring	C: Kindness, compassion and dignity	Observation	Manager's spot-check notes show that staff always acted professionally and compassionately towards service users, related to them in a kindly and friendly manner, and respected their dignity.	QA folder on server
7	Safe	S: Learning culture	Processes	Minitues of management meetings (last 6 months) show that all complaints, concerns and incidents were properly reported and acted upon to improve the quality of the service.	Management folder on server.
8	Well-led	W: Partnership and communities	Feedback from partners	Emails from local hospital trust over last 12 months show that there were some concerns regarding transfer to and from hospital for some service users. Main issues related to lack of information in referral notes from service and delays in transferring service users back to the service following hospital treatment.	Manager's folder on server.	Address these issues in upcoming managers' and staff meetings.
9	Responsive	R: Person-centred care	People's experience of health and care services	Results of service user satisfaction surveys show that 70% of people feel their care is geared towards their individual needs and wishes.	QA folder on server.	Need to address issue of other 30% who do not feel their care is addressing their individual needs and wishes.
10	Safe	S: Safe and effective staffing	Processes	Analysis of last 3 months' shift patterns show that there were 8 occasions where there were staff shortages on during the morning and afternoon shifts.	Management folder on server.	Need to explore in more detail reasons for shortfalls and review contigency plans, e.g. use of agency as well as bank staff.

wdt_ID	Evidence category	Examples
1	People's experience of health and care services	Satisfaction surveys; daily notes; care plan reviews; complaints; informal conversations; feedback from relatives or other representatives
2	Feedback from staff and leaders	Results from staff surveys; trainee surveys; interviews with individual or groups of staff; staff focus groups; interviews with leadership of a service; evidence from provider's self-assessments; compliments and concerns raised with CQC
3	Feedback from partners	Commissioners; other local providers; visiting professionals; professional regulators; multi-agency bodies
4	Observation	Interviews with staff and professionals who work in the service; Healthwatch and other partners; Experts by Experience support; observing care; observing the care environment, including equipment and premises
5	Processes	Policies and procedures; care plans; risk assessments; training records; recruitment records
6	Outcomes	Mortality rates; hospital admission rates; infection control rates; quality of life assessments