What does ‘well-led’ mean?

According to the CQC,  a ‘well-led’ service (in both the adult social care and healthcare sectors) is one where :

…the leadership, management and governance of the organisation make sure it’s providing high-quality care that’s based around your (the service user’s) individual needs, that it encourages learning and innovation, and that it promotes an open and fair culture.

But what does this mean in practice?  The CQC, in their guidance material, ‘break down’ the ‘well-led’ domain into five key lines of enquiry (KLOEs), which are intended to help both inspectors and managers find evidence for ‘well-led’.  These KLOEs are then further broken down into a number of ‘sub-KLOEs’ or prompts.  If we stick with the five main KLOEs for the time being, then we start to get an idea of the questions we would need to ask in order to ascertain how ‘well-led’ a service is:

W1: Is there a clear vision and credible strategy to deliver high-quality care and support, and promote a positive culture that is person-centred, open, inclusive and empowering, which achieves good outcomes for people?

W2: Does the governance framework ensure that responsibilities are clear and that quality performance, risks and regulatory requirements are understood and managed?

W3: How are the people who use the service, the public and staff engaged and involved?

W4: How does the service continuously learn, improve, innovate and ensure sustainability?

W5: How does the service work in partnership with other agencies?

So much for the questions: what do they mean in practice?  Or, more precisely, what kinds of evidence would an inspector (or manager for that matter) need to look for with regards to each of these KLOEs? 

The CQC does in fact provide its own guide for gathering evidence for all the domains and KLOEs, which for ease of access and clarity I have reproduced here.1   However, if we take a closer look at one particular example, that relating to W1, and more specifically, the issue of staff feedback, things are not necessarily that clear when it comes to gathering evidence.  The CQC suggest that inspectors look at staff feedback relating to:

  • The vision and values of the service, and how these are developed, discussed, put into practice and reviewed
  • The culture at the service
  • Whether staff understand how to raise concerns /‘whistle blow’
  • Experiences of raising concerns with leaders and managers, and the outcomes
  • How well leaders / managers and staff teams communicate
  • How leaders and managers give staff feedback about performance
  • Whether staff from different ethnic and belief groups are treated equally
  • How leaders and managers promote equality and tackle discrimination
  • Training / support received about issues facing LGBT people using the service

To be fair to the CQC, they are deliberately not being too prescriptive because they realise that different services will do things differently and have different types of evidence to demonstrate ‘well-led’.  However, if we just take the first two bullets points (visions and values, and the culture of the service), what kind of evidence would demonstrate a ‘well-led’ service in this particular area? 

Regarding the first point, one option is simply to ask a sample of staff members what the vision and values of their service is.  If you are met with blank stares this probably tells you all you need to know about how engaged managers are with their staff teams.  But even if staff can tell you what the vision and values of the service are (which should be made clear as part of every new staff member’s induction) do they actually understand what they mean in practice? 

As far as the culture of the service goes, the first problem is defining what ‘culture’ actually means.  As I have discussed elsewhere, the concept of organisational culture is quite complex – although not some mysterious and ethereal entity that some people seem to think it is (which is usually an excuse for not trying to change it!).   Therefore it might be difficult for staff members to give an accurate description of the culture unless they are given lots of prompts – which would rather defeat the object of trying to be ‘objective’ in the evidence gathering process.

The point I’m getting at here is not to criticise the CQC’s questions regarding evidence, but rather to point out that it may not be as easy as it seems to provide meaningful answers to such questions.  For me this highlights the importance of allowing enough time, with the appropriate level of knowledge and expertise, to be able to properly collect and examine evidence of quality across the whole service.  But as I pointed out in my previous post on Whorlton Hall, the CQC is already stretched when it comes to trying to inspect a whole service in a couple of days.  This is one of the reasons I suggested that perhaps they should focus on ‘well-led’ as a starting point because this will give a pretty good indication of what the service is like with regards to the other four domains (safe, effective, caring and responsive).   Another option would be to bring in someone else from the outside to conduct an initial review of ‘well-led’ in order to identify any serious issues in this area (and by extrapolation, in other aspects of the service as well), prior to the actual CQC inspection.

Of course, there are plenty of other ways of trying to ‘measure’ how well-led a service is, but if the CQC has its own particular way of addressing this question it would seem to make sense to adopt a similar or even identical approach to the one they use.  This is not because the CQC’s way of looking at leadership and governance is any better than anyone else’s, but simply that at the end of the day they will be ones who decide whether they are satisfied that a particular service is well-led, and this will based on their own understanding of what ‘well-led’ means. 

  1. The original source can be found at https://www.cqc.org.uk/sites/default/files/20180530%209001095%20ASC%20assessment%20framework%20with%20sources%20of%20evidence%20v4%2000.pdf []