The Care Quality Commission (CQC) has released new quality statements and evidence categories under its single assessment framework, which will be officially launched later in 2023. Here we explore what the "Well-led" statement means.

When it comes to the new 2023 CQC inspection process in the UK, being "well-led" essentially means having the right leadership, management, and governance in place to make sure your GP practice provides high-quality, patient-centred care. It also involves supporting continuous learning and innovation within your practice, while “fostering a culture of openness and fairness”.

While this might seem straightforward, it's actually the most critical aspect to focus on as you prepare for the inspection. Knowing how to care for patients is one thing, but setting up the necessary structures to meet the requirements takes time and a solid understanding of what the CQC expects.

Recap: What has changed with the new 2023 inspection process?

Historically, the CQC had a separate assessment framework for primary medical care providers. However, with the introduction of the new single assessment framework, there will be one set of expectations for all health and social care providers in England.

Providers should start preparing for the new process now by reviewing their policies and procedures, gathering feedback from patients and staff, and developing a plan for continuous improvement.

• August 2023: The CQC rolled out its new provider portal, notifying providers individually when they're able to sign up in stages and provide support and guidance.
• November 2023: The CQC will start to use its new assessment framework in southern England. 
• 2024: The CQC will roll out its new assessment framework to all providers in the rest of the country.

The CQC has said that it will provide more detailed information about the rollout plan in the coming months.

The process will be more focused on assessing the quality of care and less on compliance with regulations. The inspectors will use a variety of methods to gather evidence, including talking to patients and staff, reviewing records, and observing the service.

Are we a Well-Led practice?

For GP Practices, being "well-led" involves not just delivering excellent care but also having the right leadership and management practices in place, which requires a good grasp of the CQC's expectations and the ability to adapt to any changes they make in their approach.

Inspectors will also conduct structured conversations with managers and other leaders to assess their understanding of the service's strengths and weaknesses, and how they plan to improve. The CQC will also look at how providers involve and engage staff, people who use services, and their families and carers in decision-making.

For a service to be well-led, the CQC inspectors will look for evidence that the provider has:

• A clear vision and direction for the service.
• Effective leadership and management.
• A culture of continuous improvement.
• A commitment to providing high-quality care.
• A focus on the needs of patients and service users.

The inspectors will gather evidence to support their judgements by talking to patients and service users, staff, and other stakeholders. They will also do an observation of your service, and want to know about your policies and procedures management – are they up to date, have your staff read and understood them, are they easily accessible and reviewed regularly?

What inspectors may want to know

Here are some specific things that the CQC inspectors might look for in relation to meeting the requirements for the 'Well-Led' category:

• Does the provider have a clear vision and direction for the service?
• Is the leadership team effective in setting and achieving goals?
• Is there a culture of continuous improvement in the service?
• Is the provider committed to providing high-quality care?
• Do you focus on the needs of patients and service users?
• Do you have effective systems in place to manage risks?
• Do you have a robust complaints and feedback system?
• Do you have a clear plan for responding to any areas of improvement that are identified?

There are a few tips available for primary care providers on what to prepare for an inspection relating to the Well-Led category. Here are a few:

• Demonstrate clear leadership and governance. This includes having a clear vision and mission for the service, as well as effective systems in place for decision-making, risk management, and staff management.
• Show a commitment to continuous improvement. This means having a process in place for identifying and addressing areas where the service can improve.
• Engage with patients and staff. This means listening to their feedback and involving them in decision-making.
• Build partnerships with other organisations. This can help to improve the quality of care and support the service's overall goals.
• Demonstrate learning and innovation. This means being open to new ideas and ways of working.

Here are some additional tips that you may find helpful:

• Review your policies and procedures relating to leadership, governance, continuous improvement, engagement, partnerships, and learning and innovation. Make sure that they are up-to-date and that they meet the requirements of the CQC.
• Gather feedback from patients and staff on their experience of your leadership and governance. This will help you to identify any areas where improvement is needed (keep a copy on hand in a central location so it is accessible).
• Develop a plan for continuous improvement. This plan should identify areas where the service can improve and set out how these improvements will be made (they may ask to see a copy).
• Are all your staff recruitment details recorded? Training records, vaccination status (in accordance with UKHSA guidelines), proof of eligibility to work in the UK, DBS checks, and references will be checked (for staff employed over 10 years previous, you may need to do a risk assessment for any missing information, e.g. a nurse employed 10 years before with no record of interviews or references, but registration is up to date with NMC, earliest payroll dates and NI etc.)
• Create opportunities for patients and staff to be involved in decision-making. This could involve setting up a patient and staff advisory group or holding regular meetings with patients and staff. Stay attuned to all forms of patient feedback, including complaints, national surveys, NHS choices, etc. Demonstrate how you identify recurring themes and the actions taken. Outline your methods for informing patients about data usage, available services, and health advice, and describe your patient engagement strategies.
• Be familiar with the information that the CQC possesses about your service, including patient surveys, QOF data, cervical screening statistics, cancer service and childhood immunisation data, prescription data, and input from stakeholders like ICB & Healthwatch (you may want to build up your own library of evidence that you can present to them if asked).
• Build relationships with other organisations that can support your service. This could include other primary care providers, hospitals, social care providers, or voluntary organisations.

Using FPM’s market-leading compliance system FPM Core is a great way to ensure you are up to date with all your CQC and compliance needs. Find out more about Core’s headline features and use the form to contact us if you’d like to know more about this market-leading system.