What makes care outstanding?

This research looks at what makes care outstanding.

We commissioned the King's Fund to carry out this research. This is a summary of their full report.

Summary

In 2021, the Care Quality Commission (CQC) – the independent regulator of health and social care in England – started a major programme of change. Three independent reviews in 2024 and 2025 found serious problems with the way CQC put the changes into practice (Care Provider Alliance 2025; Dash 2024; Richards 2024). As a result, CQC is now rebuilding its approach to regulation. This includes developing 4 sector specific assessment frameworks.

Currently, CQC is using the single assessment framework, introduced in 2023. This applies to all health and social care services. It is based on 5 key questions that check whether services are:

• safe
• effective
• caring
• responsive
• well-led.

Under each question, there are quality statements. The quality statements show what is needed from providers, commissioners and system leaders for the delivery of high-quality care. For the services CQC rates, it gives one of 4 ratings:

• outstanding
• good
• requires improvement
• inadequate.

CQC gives ratings for each of the 5 key questions. Depending on the type of service, CQC then combines the ratings at the service, location and/or trust level.

Our project

The King’s Fund has a research partnership with CQC. As part of this partnership, we were asked to do some work focused on what makes care outstanding.

Providers and inspectors often say it is hard to tell the difference between good care and outstanding care. Our research aimed to develop principles that explain what outstanding care looks like and how it is different from good care. We wanted to:

• identify the areas the principles should cover
• consider whether they should vary across the different sectors that CQC’s assessment framework covers
• consider whether they should vary across the 5 key questions in CQC’s assessment framework
• explore how the principles could be used in practice
• explore whether principles designed for providers could also help with local authority assessments.

To do this, we reviewed existing literature and interviewed a range of stakeholders. We then refined the principles through stakeholder workshops (see below for more information). We also gathered views on how these principles might be applied. For more information on this, see the section on How the principles might be used.

The principles are not a description of CQC’s current ‘outstanding’ rating. Instead, they provide insights into what outstanding care looks like. This can support CQC’s ongoing work on its assessment approach. They are also intended to help provider organisations understand what outstanding care means. As CQC develops its assessment frameworks, it can decide how and when to use the principles and supporting research. For example, it could explore which regulatory processes or functions they are most relevant to.

This project started in March 2025, and we shared our findings with CQC in July 2025.

Our approach

The project had 2 phases.

Phase one

In phase one, we reviewed the literature on outstanding care. We also carried out 21 semi-structured interviews with stakeholders (between April and May 2025). Interview participants included:

• CQC staff
• a small number of staff from provider organisations (primary and secondary care)
• Experts by Experience (people with lived experience who join CQC inspection teams.

The interviews explored:

• what outstanding care looks like
• how it differs from good care
• how principles could help identify outstanding care.

From our analysis of the literature and interviews, we developed 5 draft principles for outstanding care.

Phase two

In phase two, we ran 6 workshops with a total of 48 participants:

• 3 workshops with providers. These included participants from different sectors (community, secondary, tertiary and adult social care). Participants were also from a mix of NHS, independent and voluntary organisations. Most had services that CQC had rated outstanding or good
• 2 workshops with Experts by Experience
• one workshop with CQC operational staff, including current or former inspectors.

The workshops tested, revised and refined the principles. We also asked participants how they might use the principles.

Finally, we held an engagement workshop with CQC local authority policy staff. This was to share our findings and discuss whether the principles could apply to their work.

What is outstanding care?

We used our literature review, interviews and workshops, to explore the question: What does outstanding care look like?

We found that it varies across different settings. However, there is broad agreement on its key features. People described outstanding care in 3 main ways:

• In comparison with other care, services or organisations.
  Many people explained outstanding care by comparing it to good care. They described it as care where staff go ‘the extra mile’ or do something ‘above and beyond’.
• It is something you can feel.
  Others said that outstanding care is something you know when you experience it or see it. However, it can be hard to define or measure.
• It is a different way of delivering care.
  People also saw outstanding care as care delivered consistently well. It also involves a strong commitment to learning, innovation and continuous improvement.

From the literature review and our discussions, we identified the key features of outstanding care. We outline these below.

Person-centred care

For people using services, care feels outstanding when it is tailored to their individual needs and preferences. It recognises their strengths and treats them as a ‘whole person’.

Person-centred care looks different in different settings. For some, continuity of care is most important. Across all sectors, however, our findings highlighted 2 essential features:

• a strong focus on the needs and wishes of the individual
• active involvement of people in decisions about their care.

Many stakeholders described this relational approach as key to outstanding care. This was particularly true for Experts by Experience. They emphasised the importance of staff making genuine connections with the people they care for. They also thought it was about staff being curious about their lives. This means understanding their needs. It also means giving them the power to influence their care, where that is what they want.

Leadership

Our research highlighted the critical role of excellent leadership in delivering outstanding care. CQC has long recognised this link.

Leadership influences care in many ways. The literature and our interviews focused on how leaders shape organisational culture. It also considers how they support staff wellbeing. These in turn affect the quality of care.

Outstanding care happens when staff feel engaged, motivated and empowered to take ownership of their work. This environment encourages innovation and continuous service improvement.

Participants described different leadership styles. A common theme was leadership that is flexible, collaborative and shared – that is, it is not always ‘top-down’.

Equity and inclusion

Outstanding care prioritises equity and makes sure everyone is treated fairly and included. This applies to both people using services and staff. The literature shows that organisations with an inclusive culture usually provide better care. Meanwhile, ignoring diverse needs can lead to poor experiences and outcomes.

Although this came up less often in interviews, some people linked equity and inclusion to person-centred care. They also linked it to creating a welcoming environment and focusing on those with the worst health outcomes.

Learning and improvement

Making learning and improvement part of everyday practice is key to high-quality care. This came up in our interviews and workshops. We heard that outstanding care comes from a commitment to continuous reflection and improvement. This means regularly using data and feedback from staff and people who use services, to spot areas for change and make things better.

This theme is closely linked to leadership. This is emphasised in the literature. It highlights the link between a learning culture and a form of leadership that creates a ‘learning organisation’.

Innovation

Innovation plays a key role in improving care for people who use services. In our interviews and workshops, many people said that innovation is what sets outstanding care apart from good care. They stressed that innovation should be an ongoing process, shaped by staff and user feedback and by looking at outcomes. It is not just about having one clever feature or a new piece of technology.

Innovation works best when combined with continuous learning and inclusive leadership. Together, these help to create an environment where staff feel able to find new and better ways of doing things.

Principles for outstanding care

Based on our literature review and interviews, we developed 5 principles for outstanding care. We refined them through stakeholder workshops.

There is a lot of overlap between the principles and the features of outstanding care set out above. But there are 2 key differences, because the focus of the principles is on outstanding care in practice.

• First, we brought together 2 connected themes from the literature and interviews. Learning and innovation are grouped into a single principle.
• Second, we also grouped some related ideas that came up across the themes into a single principle. This is focused on a ‘framework’ for outstanding care. This is the principle of having a purposeful approach to making a positive difference.

The principles are:

• interlinked and reinforcing – they should be considered together
• high-level descriptions – they give a sense of what outstanding care looks like for CQC and providers
• universal – they are designed to apply across all sectors that CQC regulates. However, they also recognise that outstanding care varies by context.

We now set out each principle, with a definition and illustrations of how the principle could look in practice. Together, they reflect common features of outstanding care across different settings.

Principle 1: Delivering truly person-centred care

Definition: Outstanding care is always highly responsive to individuals’ needs, preferences and aspirations, recognising what is important to people who use services, their strengths, cultures and histories.

Below are some illustrations of what it could look like.

• Staff establish a genuine and deep connection with those they care for and demonstrate real curiosity about what matters to them and how to meet their needs.
• Kindness and dignity are central to every interaction between staff and those they care for.
• People using services have autonomy and the power to have their needs and wishes communicated and to influence their care.
• Families, carers and people who use services are encouraged and actively supported to be active partners in their care, leading to exceptional levels of satisfaction.
• Care goes beyond meeting clinical or personal care needs. It also supports and empowers people to achieve what is important to them.
• Care that is joined up for each individual along their care ‘pathway’, within and between services, is prioritised.

Principle 2: Embedding a culture of compassionate and inclusive leadership

Definition: Outstanding care happens when leaders foster an open, psychologically safe, inclusive and values-driven culture that is focused on people who use services and empowers staff.

Below are illustrations of what it could look like.

• Leadership is distributed, supportive and inclusive.
• Leaders are visible, accessible and responsive to staff and people who use services.
• Values, including expectations for high-quality care, are truly people focused and consistently lived throughout the organisation.
• Staff are highly engaged, respected and supported to learn and develop.
• Staff have a clear sense of belonging, feel safe and are encouraged to speak up and are empowered to make decisions in response to the preferences of people who use services.
• Leaders consistently embrace opportunities available to their service or organisation to make a positive, tangible difference to the local community, economy and environment.

Principle 3: Prioritising equity and inclusion

Definition: Outstanding care happens in an environment that is inclusive, prioritises equity and actively embraces diversity among people who use services and staff.

Below are some illustrations of what it could look like.

• Care environments are welcoming and actively value and respect all people.
• Diverse perspectives are sought and celebrated.
• Partnerships with communities and community organisations are actively developed, to co-design and co-deliver services.
• Organisations and services challenge themselves about the particular contribution they can make to tackling health and care inequalities.
• Organisations and services promote equity and proactively respect human rights.
• There is clear accountability for equality and inclusion, with measurable goals and regular reporting.

Principle 4: Continuously integrating learning into practice to drive improvement and innovation

Definition: Outstanding care happens when a learning mindset is embedded in teams and organisations, with a focus on evolving practice and continuously sharing knowledge.

Below are some illustrations of what it could look like:

• Continuous reflection, learning and improvement are part of regular practice.
• There is an open culture that is honest about challenges and mistakes, and values these as opportunities for learning.
• Innovation is contextual, purposeful and enables consistently better outcomes for staff and people who use services.
• Quantitative and qualitative data is used meaningfully to drive improvement.
• Learning is systematically shared internally and with other organisations to support system integration and improvement.
• Relevant learning from beyond the organisation and from other sectors is integrated to consistently improve care.

Principle 5: Having a purposeful approach to making a positive difference for people who use services, staff and the wider system

Definition: Outstanding care comes from a clear and deliberate focus on making a positive difference for people who use services, staff and the wider system and is evidenced in key outcome measures and feedback from people who use services and staff.

Below are some illustrations of what it could look like:

• Outcomes and experiences for people who use services are excellent and there is a constant drive to improve them.
• There is a clear vision for outstanding care and how all those responsible for care delivery can provide it.
• Providers are outward looking and work in partnership to meet the needs of those in their care and, where appropriate, the needs of the wider community.
• Effective governance, processes and systems are in place to identify and drive positive outcomes.

How the principles might be used

Our research explored not only what the principles for outstanding care should look like, but also how they could be applied. Overall, experts by experience and provider organisations saw value in the principles. Views from CQC staff were mixed.

Possible uses include:

• informing CQC’s revised assessment framework
• supporting judgements on outstanding care in quality panels. However, some felt that sector-specific detail would be needed
• having them included in training and induction for CQC inspectors and experts by experience
• helping provider organisations identify areas for development and shape improvement plans
• communicating what outstanding care looks like across provider organisations.

However, some participants questioned their usefulness without sector-specific detail. They also raised concerns about how the achievement of broad principles could be evidenced.

Considerations for using the principles

To make the principles effective, several factors need attention.

• Clarify their purpose. The principles are high-level guides, not checklists or performance criteria. Clear framing and design will help avoid confusion.
• Ensure alignment. The principles must fit with CQC’s wider work on assessment. This will require an iterative process and further engagement with staff and stakeholders.
• Confirm the sector approach. Most of our participants agreed on a single set of universal principles. However, views were mixed on whether they should apply across all sectors. CQC will need to decide how the principles link to sector-specific frameworks.

Usefulness of the principles for local authority assessments

CQC introduced local authority assessments at the end of 2023. These assessments check whether authorities are meeting their duties under Part 1 of the Care Act 2014. Our research explored whether our principles could help with these assessments.

CQC’s local authority policy team is responsible for the local authority assessment approach. Team members reviewed our principles for outstanding care and gave some positive feedback. They suggested the principles might help in calibration (quality assurance) panels.

However, they agreed that the principles only cover a small part of what local authority assessments involve. They felt that significant extra work, or a different set of principles, would be needed for them to be fully useful.

Limitations of this work

It is important to note some limitations of this work.

Focus of the research

We looked at what principles for outstanding care should be. We did not look at whether principles are the best way to define outstanding care compared to other approaches. Exploring alternative methods could be valuable.

Purpose of CQC’s outstanding rating

The purpose of CQC’s outstanding rating was not included in the scope of our work. However, it came up during review. This suggests CQC should clarify the intended purpose of the rating.

Alignment with wider work

Our research ran alongside CQC’s broader work on revising its assessment approach. We did not have enough detail on that work to frame our workshops. This may have affected how the principles for outstanding care that we developed were received. CQC needs to do further work to decide how the principles align with its wider work.

Workshop recruitment challenges

• Some sectors were underrepresented in the workshops. This was due to the timing of the workshops and individuals’ availability. A key example is primary care.
• Provider workshops were aimed at those rated outstanding or good. This was so they could describe the difference between the two. However, recruitment difficulties meant we decided to include providers with other ratings. This meant some lacked direct experience of outstanding care. However, their perspectives were still useful, given the principles could support improvement work.
• More engagement will be important as CQC continues its work on the assessment framework. This should include a wider set of providers.

Read the full report

Full report: What makes care outstanding? (kingsfund.org.uk)