CQC quality statement — Well-led
Learning, improvement and innovation
"We focus on continuous learning, innovation and improvement across our organisation and the local system. We encourage creative ways of delivering equality of experience, outcome and quality of life for people. We actively contribute to safe, effective practice and research." In MyCareCompliance, 16 mapped checks across 15 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.
- 16 mapped checks under the "Learning, improvement and innovation" quality statement
- Evidences 1 regulation: Regulation 17 — Good governance
- Failed checks become tracked improvement actions with an owner, due date and evidence
The 16 checks
- Regulation 17 — Good governanceAppraisal Audit
Is there evidence that actions and training needs identified in previous appraisals have been completed and followed up?
What we look for: Track the goals from the previous year's appraisal to the current one. Good looks like clear evidence that promised training was booked and goals were reviewed. Fail if the same unaddressed goals carry over year after year.
Evidence: Previous year appraisal forms, training certificates, supervision notes showing follow-up
- Regulation 17 — Good governanceBusiness Continuity
Is the BCP regularly tested through simulation (tabletop exercises) and updated following real-life disruptions?
What we look for: Look for evidence of 'dry runs' (e.g., a tabletop exercise simulating a cyber attack or extreme weather). If a real disruption occurred recently, verify that a debrief was held and the BCP was amended with lessons learned. Fail if the plan is never tested.
Evidence: Simulation records, Post-incident reviews, Updated BCP versions, Incident reports
- Regulation 17 — Good governanceCompliments / Feedback
Is collected feedback formally analysed and integrated into the overarching service quality assurance audits and provider information returns (PIR)?
What we look for: Review the latest QA reports. Feedback and compliments data should feature heavily in leadership's assessment of service quality. A fail is management undertaking QA audits without referencing or utilizing the voice of the service user.
Evidence: Quarterly QA reports, annual review reports, PIR drafts, governance meeting minutes
- Regulation 17 — Good governanceDaily Care Records Audit
Is there evidence of management routinely auditing daily care records and taking action on poor record-keeping?
What we look for: Review the service's internal audit records. Good looks like monthly record audits with targeted feedback to staff who write poor notes. A fail is management failing to spot or address chronic poor record-keeping practices.
Evidence: Record audit tools, staff supervision notes, team meeting minutes, spot check records
- Regulation 17 — Good governanceElectronic Call Monitoring
Does the Registered Manager conduct monthly analysis of ECM data to identify trends in punctuality, continuity, and staffing capacity?
What we look for: Review the monthly management reports derived from ECM data. Good looks like the manager analyzing late calls, short calls, and continuity of care to drive improvements (e.g., rescheduling poor routes, recruiting in specific postcodes). Merely collecting the data without using it for service improvement is a fail.
Evidence: Monthly manager audits, KPI reports, staff meeting minutes, continuous improvement plans
- Regulation 17 — Good governanceEmergency / On Call
Does the registered manager regularly audit the on-call logs to identify trends, response times, and areas for service improvement?
What we look for: Look for evidence that management analyzes out-of-hours data (e.g., peak call times, frequent staff sickness, repeat client falls). Good practice uses this data to adjust rotas or provide targeted training. A fail is treating on-call logs purely as a diary with no overarching analysis or continuous improvement.
Evidence: Quarterly on-call audits, management meeting minutes, quality improvement plans
- Regulation 17 — Good governanceFalls Management
Is there consistent management oversight, including trend analysis of falls, to drive continuous improvement?
What we look for: Review the manager's monthly or quarterly quality audits. Good looks like analysis of falls by time, location, staff member, and service user to identify trends and implement service-wide improvements. Fail if no thematic analysis is conducted.
Evidence: Monthly falls analysis reports, clinical governance minutes, lessons learned logs
- Regulation 17 — Good governanceGovernance / Quality Assurance
Is there an active Continuous Quality Improvement Plan (CQIP) or Service Improvement Plan that drives changes based on audit findings, incidents, and feedback?
What we look for: Examine the current improvement plan. It should be a living document, actively updated with closed actions and new objectives. Fail if the plan is static, out of date, or lacks input from recent audits or CQC inspections.
Evidence: Continuous Improvement Plan, Service Improvement Plan, Meeting minutes discussing the plan
- Regulation 17 — Good governanceHospital Transitions
Does management audit hospital readmission rates and delayed discharges to identify trends and improve transition processes?
What we look for: Review the service's overarching governance records. Check if the manager analyses reasons for 30-day readmissions or failed discharges to identify lessons learned (e.g., missed medication reconciliations or premature discharges). Good practice shows proactive engagement with local health systems to resolve recurring issues.
Evidence: Quality assurance reports, Audit logs, Incident reports, Meeting minutes from management reviews
- Regulation 17 — Good governanceIncidents / Accidents Audit
Is learning from incidents systematically shared with all staff to improve practice and prevent recurrence?
What we look for: Look for evidence that anonymised lessons from incidents are communicated to the wider team (e.g., "Lessons Learned" agenda item in staff meetings). A fail is a culture where incidents are dealt with in silos and the wider team remains unaware of new preventative measures.
Evidence: Team meeting minutes, staff newsletters, memos, supervision records, handover sheets
- Regulation 17 — Good governanceLearning Lessons
Are lessons learned from internal incidents and complaints effectively communicated to all care staff?
What we look for: Review the communication channels used over the last 3 months to share learning. Look for clear, actionable messages sent to all staff (e.g., changes in manual handling protocols). Fail if there is no mechanism to share learning with remote workers who do not attend the office.
Evidence: Team meeting minutes, staff newsletters, memo sign-off sheets, spot check records
- Regulation 17 — Good governanceLearning Lessons
Does the service learn from external sources, such as Safeguarding Adult Reviews (SARs), CQC reports, and local authority alerts?
What we look for: Look for evidence that the Registered Manager reviews external best practice, coroner's reports, or regional safeguarding themes. Good looks like proactive discussion of external events and applying the learning locally. Fail if the service is entirely inward-looking with no external benchmarking.
Evidence: Management meeting minutes, updated policies based on external guidance, provider bulletins
- Regulation 17 — Good governanceMissed Visits Audit
Does the Registered Manager analyse missed visit data monthly to identify trends and implement preventative actions across the service?
What we look for: Review the latest monthly quality assurance report. Look for analysis of missed visits by run, staff member, time of day, or geographical area. A fail is treating missed visits as isolated incidents without looking for operational trends.
Evidence: Monthly quality reports, Management meeting minutes, Trend analysis charts, Action plans
- Regulation 17 — Good governancePrevious Actions / QIP Review
Is there a process to evaluate the effectiveness of completed actions (closing the loop) to ensure the intervention actually solved the root cause?
What we look for: Check how actions are marked as 'closed'. Good looks like a 'check/verify' step by the manager to ensure the fix worked (e.g., a mini re-audit). Fails if actions are just ticked off when a memo is sent, without checking if practice actually improved.
Evidence: Re-audit schedules, quality assurance reports, QIP closure notes, post-action review meetings
- Regulation 17 — Good governanceSkin Integrity
Does management systematically review skin integrity incidents to identify trends and implement service-wide preventative measures?
What we look for: Review management meetings or quality reports. Good looks like a manager spotting a trend in missed cream applications and running targeted toolbox talks. A fail is treating every skin tear or pressure sore as an isolated event with no wider learning.
Evidence: Quality assurance reports, Audit reports, Incident trend analysis, Meeting minutes
- Regulation 17 — Good governanceWhistleblowing / Speak Up
Are themes and outcomes from whistleblowing concerns analyzed at board/senior management level to drive continuous service improvement?
What we look for: Review senior management or governance meeting minutes to see if whistleblowing data is discussed. Good looks like leaders identifying trends (e.g., specific rotas or managers) and implementing systemic changes. A fail is treating each concern in isolation with no overarching quality assurance review.
Evidence: Board meeting minutes, Quality assurance reports, Annual Freedom to Speak Up report, Action plans
Other Well-led quality statements
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