Sustaining improvement

Published: 3 March 2020 Page last updated: 6 March 2020
Organisations we regulate

In 2017 and 2018, CQC published reports on NHS acute trusts and NHS mental health trusts.

The reports showed how the trusts had achieved significant improvements in their ratings.

Towards the end of 2019 we revisited four of those trusts. We found out how they had sustained the improvements or improved further.

Themes from sustaining improvement

Formal QI programmes in place

All four trusts had formal QI programmes in place. These were either of their own design or programmes such as Vital Signs. They recognise the importance of involving staff in improvement work. Staff can develop ideas that improve care based on their experience. And they include the experience of people using services. In some cases, programmes are in place to train staff to train others in QI techniques.

Self-evaluation, assurance and accreditation

Self-evaluation, assurance and accreditation are at the heart of continuous improvement. Some trusts have introduced their own ward accreditation schemes. They developed metrics and audited them regularly. All four trusts have moved away from RAG ratings. Or they've augmented them with statistical process control (SPC) charts (‘plot the dots’). These better show processes are under control and measure impact more clearly. The trusts use data intelligently to help predict performance.

There's a growing number of improvement projects in each trust. So it’s important that robust assurance and risk management processes are in place. These should consider improvement projects and core performance.

Continuing focus on leadership

Leadership stability has helped all four trusts sustain improvement. Where the leadership team changes, robust succession planning continues the approach to improvement. As does linking recruitment to the trust’s values and behaviour.

Trusts recognise the importance of leadership through leadership programmes. And other programmes give staff the skills they need to step up to leadership roles. Training is seen as a high priority. A common feature of good and outstanding trusts is leaders who are accessible and approachable to staff.


Leaders need to support and engage with staff - involving them in developing the trust's vision and values. This makes a telling and ongoing contribution to driving and sustaining improvement. And it helps establish a shared culture of quality and improvement. Staff need opportunities to contribute ideas, and voice concerns and good feedback. The trusts can show they have listened to staff and taken action. Patients and the wider community have a role in improving and developing services. Then those services can be designed around people’s needs.

Recruitment and retention

Having the right number of the right staff available at the right time sustains improvement. This means thinking creatively about recruitment and retention, and deploying staff in new ways. Examples include creating pathways into nursing for healthcare assistants. Or training existing staff and giving them opportunities to progress within the trust. Initiatives to make the trust a good place to work, lead to better staff retention. For example, programmes that support physical and mental wellbeing.

Involvement with the local system

All four trusts are clear about sustaining and improving in the long term. They know it will only be possible if they are an active partner in the local system. They already take leadership roles in the systems. They work on joint initiatives such as system-wide workforce or mental health plans. The main driver of pressures in acute and mental health trusts is demand. That needs to be tackled in partnership at its source in primary, community and social care. Trusts also involve local voluntary sector organisations that may not be part of formal system arrangements.

The four trusts are:


A series of case studies showing how trusts have achieved significant improvements in their ratings - and how they have since sustained those improvements or improved further.

See also

Blog: Sustaining improvement - the story of four NHS trusts

Blog: Plotting the path to improvement

News story: Sustaining improvement - the stories of four hospital trusts

Driving improvement reports

Driving improvement: Case studies from NHS trusts

Driving improvement: Case studies from mental health trusts