Assessing quality and performance

Page last updated: 17 May 2024


Adapting our approach to trust-level assessments of the well-led key question in NHS trusts

We assess the well-led key question using quality statements at both assessment service group and trust level. At trust level, the focus is on the trust's board and senior leaders with trust-level responsibilities in the context of wider organisational performance.

We will continue to follow NHS trust methodology for providers of community healthcare and/or mental health care (typically community interest companies (CICs)) that deliver multiple services to people in a specific geographical area, similar to an NHS trust.

The first trust-level assessment of the well-led key question under the single assessment framework

The first trust-level assessments under the single assessment framework will cover all 8 quality statements under the well-led key question plus moderation. This will enable us to:

  • create a starting point or 'baseline' and issue a first rating based on a full assessment at the trust level
  • ensure that when we award our first new ratings under the new approach, we have confidence in those judgements and that we have considered the full scope of the assessment of both leadership and wider organisational performance
  • reflect the challenges faced over the last few years in updating overall trust ratings
  • recognise the changes to the area of the framework under the well-led key question and the complexity of assessing organisational leadership, culture and management.

Current ratings will remain displayed 'as is' (including Use of Resources and combined ratings) until trusts receive their first assessments under the single assessment framework. At this point, trusts will be awarded their 'new' trust-level rating for the well-led key question – existing ratings (including those for Use of Resources and combined quality ratings) will be retired.

We will initially prioritise service-level inspections using the single assessment framework. This will allow us to focus on risks to patients and to update our overall view of service-level ratings.

This approach has a number of benefits:

  • Quality at service level is important to gain a holistic view of quality at trust level. This approach would enable us to reflect a broad and up-to-date view of quality in our trust-level assessment and rating.
  • Our new integrated assessment and inspection teams will need time to build their knowledge and relationships with the trusts in their networks. We also need to make sure that we still have the expertise within each new network to carry out robust assessments at the overall organisational level and provide the support, training and guidance needed.
  • Trusts would have more time to become familiar with the new assessment approach before we start to award new trust-level ratings for the well-led key question, and we remove existing trust-level key question ratings from our website.

Working with NHS England

In our trust-level assessments of the well-led key question, we will work closely with NHS England. NHS England will use the Oversight Framework to identify where trusts may benefit from, or require, support and when and how it will intervene.

We will use the results of NHS England's oversight and assessments of trusts in our assessments.

When working together, CQC and NHS England follow these principles:

  • We work together to carry out our respective functions effectively, while recognising that each organisation is legally and operationally independent
  • We make sure our definitions, measurement and operations are based on a single shared view of quality.
  • We work to remove duplication between our organisations.
  • We focus on quality and how it is maintained and improved alongside financial sustainability.
  • We work together across all aspects of our regulatory and oversight model by:
    • sharing data and aiming to use a single, shared standard of measurement, both to review performance and to decide where to target support or oversight
    • co-ordinating how we gather evidence to plan assessment activity, using information from NHS England as evidence to inform our judgements
    • sharing information on the results of our assessments
    • co-ordinating how we engage with individual providers as well as with wider healthcare systems.


This guidance describes how we assess the well-led key question. It helps NHS trusts and foundation trusts understand what good leadership looks like. The guidance has been jointly developed by CQC and NHS England.