Well-led: the question of governance

In a previous post I argued that the CQC’s ‘Well-led’ domain was important because there appears to be a strong correlation between those services that have a positive ‘Well-led’ rating and their overall rating.  In other words, get ‘Well-led’ right and (hopefully) the rest will follow.  However, I think it’s worth taking a closer look at what ‘Well-led’ actually covers in terms of service quality and safety.

A good place to start is to see how the CQC itself defines ‘Well-led’.  In their guidance to the KLOEs and ratings characteristics for Adult Social Care services the CQC states that:

By well-led, we mean that the leadership, management and governance of the organisation assures the delivery of high-quality and person-centred care, supports learning and innovation, and promotes an open and fair culture.

With reference to ‘Well-led’ characteristics for an ‘Outstanding’ service they go on to state that:

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.

For ease of access I have reproduced the detailed characteristics of ‘Well-led’ for an ‘Outstanding’ service here.  However, I think it is clear even from this brief quote that the CQC regards leadership, governance and culture as the key drivers for a quality service.

With regards to culture I have explored this topic in a number of posts on this site.  I have also recently posted a presentation on organisational culture.  With regards to leadership, in the context of CQC regulated services I would argue that this refers particularly to the ‘people’ aspect of service management, including team management, an understanding of team dynamics, and different styles of people management.  It also links closely to culture in that leaders, and particularly senior managers, have an important role to play in establishing a particular kind of culture, and in setting the ‘tone’ for the service.  They are also expected to provide a vision, mission and strategy for the service.

Which leaves governance, which is perhaps the trickiest to define of these three key aspects of ‘Well-led’.  However, one way to approach the question of governance is to look at Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.  Regulation 17 is one of a series of regulations that the CQC uses to provide the regulatory framework for its inspections, and focuses on good governance.  There are two particular paragraphs in the Regulation that managers and providers would do well to take note of.  Paragraph 1 states that:

Systems or processes must be established and operated effectively to ensure compliance with the requirements in this Part.

The accompanying CQC guidance to this paragraph states that:

  • Providers must operate effective systems and processes to make sure they assess and monitor their service against Regulations 4 to 20A of Part 3 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (as amended). The provider must have a process in place to make sure this happens at all times and in response to the changing needs of people who use the service.
  • The system must include scrutiny and overall responsibility at board level or equivalent.

Paragraph 2 (a) then goes on to state that that such systems and processes should enable to registered manager to:

…assess, monitor and improve the quality and safety of the services provided in the carrying on of the regulated activity (including the quality of the experience of service users in receiving those services)

The guidance for this paragraph is very long but the first section is key:

Providers must have systems and processes such as regular audits of the service provided and must assess, monitor and improve the quality and safety of the service. The audits should be baselined against Regulations 4 to 20A of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and should, where possible, include the experiences people who use the service. The systems and processes should be continually reviewed to make sure they remain fit for purpose.

It is also worth pointing out that paragraph 3 is important too, because it can be the basis for prosecution if providers fail to comply with it:

17(3) The registered person must send to the Commission, when requested to do so and by no later than 28 days beginning on the day after receipt of the request—-

17(3)(a) written report setting out how, and the extent to which, in the opinion of the registered person, the requirements of paragraph (2)(a) and (b) are being complied with, and

17(3)(b) any plans that the registered person has for improving the standard of the services provided to service users with a view to ensuring their health and welfare.

Going back to paragraph 2(a), this essentially means that providers must be able to demonstrate to the CQC that their services are compliant with Regulations 4 to 20A.  In other words, the systems and processes they use for monitoring their services need to have both the scope and sensitivity to capture all aspects of quality right across the service.  Or, to put it another way, simply having a few audits and surveys in place won’t do…