CQC quality statement — Well-led
Capable, compassionate and inclusive leaders
"We have inclusive leaders at all levels who understand the context in which we deliver care, treatment and support and embody the culture and values of their workforce and organisation." In MyCareCompliance, 8 mapped checks across 7 audit templates map to this quality statement.
Last reviewed: September 2026. This guidance reflects CQC information available at the date above — always refer to cqc.org.uk for current regulatory requirements.
How we check it
Each check below is a real question from a MyCareCompliance audit template. It names the regulation it evidences, describes what an auditor looks for in good and poor practice, and lists the evidence an inspector would expect you to produce.
- 8 mapped checks under the "Capable, compassionate and inclusive leaders" quality statement
- Evidences 2 regulations: Regulation 17 — Good governance, Regulation 18 — Staffing
- Failed checks become tracked improvement actions with an owner, due date and evidence
The 8 checks
- Regulation 17 — Good governanceAppraisal Audit
Are staff given adequate notice and preparation material prior to their appraisal to enable meaningful, two-way participation?
What we look for: Check if staff complete a self-reflection or pre-appraisal form. Good looks like staff having time to reflect on their achievements and challenges before the meeting. Fail if appraisals are done spontaneously with no staff preparation.
Evidence: Pre-appraisal questionnaires, email communications, staff meeting minutes
- Regulation 18 — StaffingAppraisal Audit
Are SMART (Specific, Measurable, Achievable, Relevant, Time-bound) objectives set collaboratively for the coming year?
What we look for: Evaluate the objectives set for the upcoming year. Good looks like 2-3 clear, achievable goals with target dates. Fail if goals are vague (e.g., 'do good work') or dictated by management without staff input.
Evidence: Appraisal goal-setting sections, PDPs, mid-year review notes
- Regulation 17 — Good governanceBusiness Continuity
Does the service have a robust and tested on-call system to manage out-of-hours emergencies and immediate continuity issues?
What we look for: Review the out-of-hours logs for the past month. Check that management oversight exists for on-call decisions and that the rota ensures consistent coverage with backup options if the primary on-call person is incapacitated.
Evidence: On-call rotas, On-call logbook/system, Handovers, Lone worker monitoring alerts
- Regulation 17 — Good governanceCompliments / Feedback
Are compliments explicitly shared with the relevant care workers and the wider staff team to reinforce positive practice and support workforce wellbeing?
What we look for: Check how compliments are communicated back to the frontline. Good looks like personal thank-you letters from management, shout-outs in newsletters, or mentions in supervision. A fail is staff being unaware of compliments received about their care.
Evidence: Staff meeting minutes, supervision records, newsletters, memo emails, employee of the month awards
- Regulation 17 — Good governanceCQC Notifications Audit
Do the Registered Manager and delegated on-call senior staff accurately understand which events require a statutory CQC notification?
What we look for: Question the RM and a senior/on-call staff member on notification thresholds (e.g., pressure ulcers, police, safeguarding). Good looks like confident, accurate knowledge of the required events. Fails if on-call staff do not know what warrants an immediate notification versus local logging.
Evidence: Staff Interview notes, On-call handover records, Competency assessments
- Regulation 18 — StaffingInduction / Care Certificate
Are new starters receiving regular, documented support, mentoring, and probationary supervision during their induction period?
What we look for: Sample supervision files for staff in their first 6 months. Look for 4-week, 8-week, and 12-week probationary reviews that discuss well-being, competence, and training needs. A lack of structured support during the critical early employment phase is a fail.
Evidence: Supervision records, Probationary review forms, Mentor meeting notes
- Regulation 17 — Good governanceRota / Staffing Capacity
Is there adequate on-call and management support available during all hours that care is being delivered, including weekends and evenings?
What we look for: Review the on-call rota and logbook for the past month. Ensure a competent, trained manager/senior is always available for advice and emergency cover. A fail is staff reporting they cannot reach anyone in an emergency out of hours.
Evidence: On-call rotas, out-of-hours logbooks, staff survey results, incident reports occurring out-of-hours
- Regulation 18 — StaffingTraining Matrix Audit
Is there a clear follow-up process for staff who fail to attend training or fail assessments?
What we look for: Check records for staff who have missed booked training. Good looks like return-to-work or supervision chats to address barriers, and immediate rebooking or suspension from certain duties if unsafe. Fail if DNAs are ignored and staff continue working non-compliant.
Evidence: Training matrix, Did Not Attend (DNA) logs, Disciplinary/performance records, Supervision notes
Other Well-led quality statements
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