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The well-led CQC standard and how to achieve an improved rating

13 June 2022


  • CQC

The Care Quality Commission (CQC) uses five main Key Lines of Enquiries (KLOEs)to assess the quality of a service delivered by a healthcare organisation. One of the questions the CQC ask is: “is your care well-led?” 

The well-led KLOE concentrates on how an organisation’s management, leadership, and governance support the delivery of high-quality care. However, a prevalent challenge that many healthcare services face is consistently meeting and evidencing the requirements for well-led care.  

This blog acts as a resource to help healthcare services gain a better understanding of the well-led CQC KLOE, common challenges, and how technology, like Radar Healthcare, can support organisations to deliver well-led care and achieve an improved CQC rating. 

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How does the CQC define well-led care?

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

Requirements for services

The well-led CQC can be broken down into eight different requirements. In summary:

W1) Services are expected to have the leadership capacity and capability to deliver high-quality, safe, and sustainable care. This requires leaders and managers to have the right skills, knowledge, and experience to understand and face challenges strategically.

W2) The CQC asks if there is a clear vision and strategy to deliver high-quality and sustainable care? Realistic action plans for achieving priorities and delivering safe and sustainable care to people.

W3) Healthcare organisations need to show how they support, respect, and value their staff to be able to perform and deliver the best possible care.

W4) The CQC is interested in seeing evidence of solid structures, processes, and systems of accountability to support good governance and management and how often they are reviewed and assessed.

W5) Services are asked to show their processes for managing risks, issues, and performance and how regularly they are completing and reviewing clinical and internal audits to monitor quality, operational and financial processes.

W6) A holistic understanding of performance that sufficiently covers and integrates people’s views with information on quality, operations, and finances need to be established – and, again, this information needs to be used to measure and contribute to improvements.

W7) How are people’s views and experiences gathered and acted on to shape and improve the services and culture? This includes all service users, such as external parties and other healthcare professionals.

W8) Services need to be able to identify and evidence robust systems and processes for development and continuous improvement. The CQC wants to see how leaders and staff strive to recognise areas for improvement and what steps are in place for development to happen.

Obstacles organisations may face

Lack of communication and structure

42.9% of people in our recent CQC checklist survey stated that they are unconfident that their staff training records were up to date. The CQC’s well-led KLOE is in place to encourage managers and leaders to be well versed with their service and staff to create a fluid structure from top to bottom. Sometimes management can be out of touch with what is happening, inconsistent, ineffective, and unaware of who needs what support, due to a lack of resources, time, and experience.

None or little support for workers  

Our recent poll revealed that 40% of people within the healthcare sector believe that the biggest concern when facing a CQC inspection is their staff answering questions incorrectly. As care is such a busy, demanding, and fast-paced working environment, important things such as supporting staff and recognising their needs and wants can become secondary to other duties. However, without the correct support and encouragement, care workers can become discouraged and inexperienced and, therefore, unable to perform high levels of care.

Incidents, concerns, and events are not dealt with properly

Reporting incidents, concerns, and events allow the CQC to see that an organisation is constantly checking for risks and looking to improve its service. Surprisingly, 50% of people who answered the checklist  said that they do not have a robust and central incident log.

Evidencing action plans

Reflective practice, learnings, and/or improvements based on incidents, concerns, events, and/or risks found need to be effectively shown and delivered. However, our research shows that 53.3% of people do not have an action plan which links to corresponding incidents and audits.

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How does Radar Healthcare support well-led care?

Radar Healthcare’s centralised system supports healthcare organisations through a range of quality and compliance modules, to deliver well-led and sustainable care and prepare them for CQC inspections.

Management has full visibility of their workforce

Our software encourages open and honest collaboration and communication across a whole organisation to improve safety, outcomes, and experience.

Our workforce compliance module helps management monitor and track the progress of their employees’ training, appraisals, and more. The module is designed to be customisable and allow users complete visibility of everything that has been completed.

Radar Healthcare isn’t just there for ‘E-zec,’ it is there for us all as individuals, as managers, as leaders, and to help improve how we work. Our colleagues are really seeing the benefits of using it now, because it has revolutionised quality, compliance and risk management for E-zec.

Anna Prowse, Head of Quality Compliance and Health and Safety at E-zec

In-depth incident and event reporting

Regulators are looking for evidence of ‘ability to learn’. Our cloud-based incident management system helps our partners log incidents, and all the associated requirements, and create a strategy of action to adapt methods to prevent risks and issues from happening again.

As well as easily evidence incidents and events, this module allows organisations to collate compliments and positive feedback. This allows management to reflect on the positive impact that their staff is having on the organisation.

The number of incidents reported increased from an average of 4 per month to 35 with the introduction of Radar Healthcare - meaning the CQC can see we’re accurately reporting and actioning incidents to drive continuous improvement.

Dave Hartley-Large, Head of Governance at Spark Medical

Easily evidence action and improvement plans and drive continuous improvements

The well-led CQC along with responsive, caring, effective, and safe  (the other four KLOEs) wants to see services actively evidencing and actioning steps to make improvements. Our CQC checklist revealed that 57.1% of people do not have an action plan in place which links to the corresponding KLOE.

Luckily, Radar Healthcare embeds a culture of continuous improvement throughout our modules – allowing our partners to link action and improvement plans to each of their auditsrisk assessments, and incidents and events.

Find out if you are CQC ready with ourinteractive checklist! 

More in our latest blog series about CQC's KLOEs

  • Icon for The safe CQC standard and how to achieve an improved rating

    The safe CQC standard and how to achieve an improved rating

  • Icon for The effective CQC standard and how to achieve an improved rating

    The effective CQC standard and how to achieve an improved rating

  • Icon for The caring CQC standard and how to achieve an improved rating

    The caring CQC standard and how to achieve an improved rating

  • Icon for The responsive CQC standard and how to achieve an improved rating

    The responsive CQC standard and how to achieve an improved rating


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