CQC – How to achieve a service well led in 21 weeks

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Care Quality Commission: An action plan for a well led service

An action plan to achieve a well-led service and increase your CQC rating in 21 weeks.

The Care Quality Commission’s main goal is to make sure that patients are well looked after.

Now, of course, for patients to be in caring hands, the service provider needs to provide for their employees.

Perhaps you just got a visit from the CQC, or received an inspection report?

Is your service well-led?


Source: CQC (Care Quality Commission, UK)

Source: CQC (Care Quality Commission, UK)


What CQC rating did you get?

If your service got listed as Requires improvement, you’ve got 1 year, or less, before your next inspection.

Inadequate means the CQC will pop back within 6 months.

This means it’s…


Time to act!

You most likely got an action plan that you’re already following to improve your care facility.

This article’s focus is to improve your rating in terms of the service being well-led.

So what does the CQS mean with well-led?

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

How are your caregivers doing, are they with you?

How’s employee morale lately?

Words aren’t enough, get tangible data to show progress as you start your improvement journey.



How to monitor progress between the Care Quality Commission’s inspections

One way to demonstrate that your company is well-led is to present employee morale data to support your case.

By using anonymous feedback devices you can ask your caregivers to rate their workdays. Gauge employee engagement CQC

How many do you think would press the green smiley, instead of the red one, at the end of today’s shift?

What makes them have green days?

What needs to change, for them to not press the red button at work?



Action Plan

Let’s nurture a culture of staff wellbeing.

We’ll look at an example of an action plan to get a high rating in terms of your service being well-led, with a higher level of employee engagement.

You can follow this 21-week plan with, or without, any type of device to gauge employee mood.


Week 1: Wellbeing Team

Who is responsible for what?

Look at your current CQC action plan.

Who wrote it? Who reviewed it? Is it diverse? What roles or hierarchy levels are missing?

Create a wellbeing team with champions from all areas and backgrounds, who are interested in helping out for everyone to have better workdays.

Organize a first (fun!) meeting, assign a budget, and divide tasks. A great workplace is everyone’s job.


Week 2: Kick-off

To get a baseline of how your caregivers experience their work shifts, you need to give it some time before you have enough data.

Start as soon as possible, by launching big time, or just a modest launch.

Using devices is a visual way to show your people that you care and that you take employee morale seriously.

Explain that the purpose of gauging the mood is to improve. And that you promise to act on the data and any feedback they give. Create a progress board.

If you haven’t already, start with daily shift meetings. Work on getting a horizontal structure.


Week 3: Work on Openness

A transparent workplace is key to higher employee engagement.

Make sure to publicly share the daily employee morale results. No matter what number you get.

Make it visible and help your team leaders get familiar with the data, and their role.

Honesty is contagious! And it starts with you.

Share how YOU’RE feeling at work lately. What made you press green yesterday? What red would you love to fix first?

Lead by example and have the wellbeing team do the same.

Do people consider you to have a fair and open workplace?

  • More tips on how to create a transparent workplace.

Remember, the goal for the Care Quality Commission report is to show you have a service that is well-led. A fair and open workplace is the basis for this.


Week 4: Conversations

If you haven’t already, start with weekly meetings to accompany your daily stand-up meetings.

Get all team managers to ask:

  • What makes us press green the green button?
  • What red feedback should we fix first?

Or the equivalent if you’re gauging employee morale in another way.

This is how one manager started his journey to improve employee engagement:

“We talked to our workers to find out what was happening. I asked them very openly about what was going on. Within short, some began to talk and share how they felt.”

Start to actively listen.

Do your employees feel they can (truly) share concerns without fear of retribution? Is this the case for all your team managers?


Week 5: Communication

Where health service staff report they are well-led and have high levels of satisfaction with their immediate supervisors, patients report that they, in turn, are treated with respect, care, and compassion (Dawson et al, 2011).

Organize focus groups for all staff members to give their input on how communication could be improved.

What should we start, stop and continue doing?

Remember, this is about listening. About learning.

Avoid getting defensive.

Here’s a nurse manager sharing her favourite tips.


Week 6: Action!

What feedback have you and your team leaders collected so far?

If you haven’t started already, fix something, anything, quickly.

This is the only way you will win your people over.

You need to act.

Because if you keep doing the same thing you’ve always done, you’ll get the same results.

Start by fixing something small (‘our breakroom is always smelly’) which is “easy” to fix. Then communicate back once you’ve fixed the problem.

That is the first step to get people to provide more useful information, and start trusting that it’s SAFE to give feedback.

And that you’re committed to change.

This is what the Care Quality Commission will be looking for during their next inspection.

If you monitor staff morale and have a daily feedback tool, you can also verify the differences between your shifts. This will help you prioritise your first actions.


company mood for shift workers


Week 7: Focus on leaders

How are your team leaders doing so far?

Are they pushing for a well-led service?

Take a moment to fully focus on them and their needs.

As a leader in your organisation, what makes them press green/red? This will most likely be slightly different from their team’s reasons.

Fill in the Green/Red list and decide on what red reasons to attack first.

Are you open enough to share their feedback with the whole team?

We put together some powerful ideas to help them be better leaders.


care quality commission well-lead service


Week 7: Celebrate small wins

Celebrating in the day to day is a great way to keep morale up.

It doesn’t have to be big things.

It can be quirky little things that work well in your company culture.

  • A public board where people write down SMALL good things that happens (I calmed John down in record time after his seizure!)
  • Whiteboard to write positive messages to each other (thanks Dan for covering my shift. My kids love you!)
  • Pancake breakfast when you achieve X (7 days without being understaffed!)
  • Lollipop or a cup of tea to someone you caught doing something RIGHT (using PPE the right way)
  • What happens on a green (good) day at work? Write it on a post-it, read all notes out loud at the next shift meeting. (There was milk in the fridge for my coffee all day, yay!)
  • A new colleague just joined? Yay! Make sure they stay by arranging a Lunch Roulette.
  • 15 days without an accident! Let’s share my pack of biscuits :)

Celebrating small wins is a constant reminder that you’re going in the right direction.

Remind your leaders of the importance of the upcoming Care Quality Commission report.


Week 8: Leadership training

After 8 weeks of measuring employee morale, your organisation should have a clearer view of how managers are perceived by their teams, and where the leaders need help.

What leadership skills do they need to work on?

If you don’t know:

  • Ask your front-line staff first, THEN the managers.
  • Great opportunity to spot the differences.

What training is needed? Start preparing.

We strongly recommend ongoing leadership courses for everyone in a leadership role.

Don’t forget top management!

This is an action that should definitely push the employee engagement data in the right direction, a bit faster.

And here’s a fun idea: get your employees to develop a training video!

A great way to enlighten leaders about their needs, and give them tips to better lead your healthcare facility. How would they like to be treated?


Reports and records for the CQC

Week 9: Review records

Similar to the last point, dedicate this week to making sure that you’ve properly recorded all actions taken so far.

What do the statistics show?

How will you present this to the Care Quality Commission?

What do you need? Which records are missing, like training certificates, meetings minutes, etc?

Involve your wellbeing team and staff at all levels to make sure transparency is respected.

The CQC takes compliance seriously.



Week 10: Kindness at Work

How can you speed up to get a service that’s well-led?

Challenge your care managers to do ONE of these 7 Acts of Kindness before the end of next week.

They cost zero to implement, and almost zero in time.

Ask them to tell you which they chose.

Set the bar low so they don’t feel too pressured.

Chances are that everybody will NOT do this either way.

Change takes time.


Week 11: Lean Healthcare

Adopting lean healthcare can propel your care agency to get an outstanding CQC rating.

Get your organisation to read up, or perhaps start a course, on the benefit of lean healthcare.

Check out the NHS starter guide.

What’s the reaction from your people on the ground? How do they think this can best be implemented?

Use storytelling to win people over, and small start.

This is a marathon, not a sprint.

Also, remember to share your employee engagement data as you progress.

KPI for healthcare employees




Week 12: Conflict Resolving

When there’s high pressure on the shift, or if you’re understaffed, conflicts are more likely to pop up.

Let’s get proactive!

This is a great chance for improvement.

Organize mini-workshops to help your people handle conflict better. We are all different.

CMPA has useful hints and phrases to be used in healthcare settings like “I’ve made different observations, probably because I had different experiences….”

Better yet: prioritise having enough staff to cover your care facility’s shifts.

Being understaffed is one of the main stress factors for healthcare workers. Improving staff morale should help you retain your workers, and keep sick days at bay.

You can also ask your residents or patients for their input to help minimise the impact of conflicts.


Week 13: One-on-one meetings

There are many ways to make care workers feel informed and cared for.

Successful healthcare leaders use informal chats, one-to-one meetings, daily huddles, appraisals, team meetings, Whatsapp messages, all-staff meetings…

Take a week where your team managers schedule upcoming individual meetings.

Remember, a lot of times just making people FEEL listened to, has a tremendous impact.

The meetings can be short and should be repeated over time. This will make the appraisals a lot easier.

“Our staff appraisals used to be complex conversations. The Celpax gives our employees a way to raise issues at work without it being in a personal way. That’s been valuable”, says this UK user.

PS. You’re doing 360 feedback, right?

Service well-lead, leadership action plan CQC


Week 14: How can we support you, our workers, better?

Based on what you found out during the individual meetings, you can now focus on group actions.

Act on their concerns!

Get them to share their views and ideas to develop the service and improve. How would they like to be supported while doing this?

What is important to them?

Remember that anyone on your team can get asked during the upcoming Care Quality Commission inspection. You need to work on the group as a whole.

Here you can find materials to share your results in a fun way.

CQC action plan for a service well-lead


Week 15: Celebrate diversity

There’s no need to wait for Global Diversity Awareness Month, we can celebrate diversity any day of the year!

Ask your workforce for ideas to keep it real.

Would they like to do a Bollywood dance class? Share personal stories? How can caretakers be included?

Start the conversations.

Make sure your people feel you are a truly inclusive and open workplace, and take action if that’s not the case.

Also, is the diversity represented on a leadership level?


Week 16: Collect Examples… and copy with pride!

Get your employees to share examples of best-practice ideas they’ve used at other health and social care services they’ve worked at.

Then copy with pride to increase your CQC rating!

Perhaps you can even start a collaboration with another organisation to share best practice tips.

Or reach out to a local college or university and ask for help in your quest for a service well led.

Your local council most likely also has tips for your care home, mental health service, etc.


Week 17: Hiring

Involve your employees and get them to interview new staff.

What can you learn from the questions they ask?

Or the way they conduct the interviews, follow-up, etc?

Do the same for the onboarding and orientation process.

And hey, start peer-reviewing while you’re at it! Then follow-up and measure if you’re improving your KPIs in terms of the Care Quality Commission.


Week 18: Carers committee

Ask for volunteers to create a carers committee if you don’t have one already.

Then reach out to families and ask for their feedback.

Again, acting on the feedback and reporting back is crucial.

Create a ‘You said we did’ board to achieve openness.

Getting employees to listen to the families’ feedback, combined with patient feedback, will be useful and help your organisation improve continuously.

Action plan for a service well-lead

Week 19: Mentors

Get front-line staff to mentor your CEO and board.

And ask who, at any level, would like to volunteer to become a mentor.

If someone has gone through a company culture improvement at another workplace, have him or her act as a mentor to your wellbeing group.

Or learn from others who’ve improved their Care Quality Commission rating at other home care agencies, NHS trusts, etc.

Perhaps you can do a similar journey?


Week 20: Challenge the status quo

How often do you innovate at work? Or give others the chance to do so?

Use broad questions. I.e. how can we improve our service? If budget wasn’t an issue, what would you do?

What change opportunities do they see?

How would your care workers address this?

Step outside your comfort zone and try something new!

Then validate the impact in your daily employee engagement data.


Week 21: Promotions

How do you promote new leaders?

This is one area where you really, really want to hear the truth from your team.

Hire for people skills, not tenure, or for simply “showing up”.

The role to lead should go to people who like to lead, and to those who are perceived as good at leading by their coworkers.

Nurture those with potential, and make sure they know you see them as future leadership material. You could do work shadowing and have them step in if a manager is unavailable one day, or start mentoring programs.

Do people consider you to have a fair workplace when it comes to promotions?


Hope you got some inspiration for your CQC action plan!

You obviously don’t start an action plan like this just to get a better Care Quality Commission report.

You do it to improve for both your patients and your health care employees.

There is an increased emphasis on culture and leadership in the last iteration of the CQC  framework.

As an independent regulator of health and social care in England, the CQC recently hired Deloitte to evaluate its service.

One of their findings for the healthcare services well-led framework (WLF) was to ensure that the WLF used by the Care Quality Commission and NHS England/NHS Improvement is “sufficiently focused on leadership, culture, improvement, and people management as these factors are often identified as the root drivers of quality and efficient use of resources”.

The road to an outstanding practice usually isn’t a straight one.

But it will be well worth the journey!



Smiley feedback terminal Celpax

A simple way to monitor and keep staff morale high.


Early warning system for employee engagement

KPI for healthcare employees



Rebecca Lundin, CelpaxHej! I’m Rebecca, cofounder at Celpax. We manufacture simple tech tools to improve workplaces. And build a better society while at it. Let’s talk more about the Care Quality Commission’s ratings and how to get a service well led? 

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