The PSC case-studies: entry

Building a CQC action and governance framework for a Mental Health Trust

The PSC Transformation team supported South London and Maudsley mental health trust to evaluate and design improvements to its Care Quality Commission (CQC) action planning and governance processes.

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Senior leaders at the South London and Maudsley Mental Health Trust had identified that existing processes were cumbersome and resource-intensive, lacked rigour and consistency, and placed insufficient focus on capturing metrics of impact for patients and staff.

Our team worked collaboratively with the Trust’s corporate quality team and six operational directorates to:

• Design an ideal future state for CQC action planning and governance at the Trust
• Conduct gap analysis conversations comparing the future state with the current state
• Develop a clear and comprehensive CQC action planning and governance framework
• Build a user-friendly CQC action plan template to underpin the framework

Building a CQC action and governance framework for a Mental Health Trust

Ideal future state

Together with Trust colleagues, we co-designed an ideal future state model for managing CQC-prescribed actions. This model established aspirational standards of practice for CQC action planning, delivery, tracking and governance processes.

Current state gap analysis

We conducted gap analysis conversations with the corporate quality team and operational directorates, evaluating to what extent current CQC processes at the Trust were in line with components of the future state model. These conversations identified areas of existing best practice and highlighted areas of potential improvement.

CQC action planning and governance framework

Informed by these findings, we designed the framework – with the objective of setting out comprehensive CQC processes to support delivery of outstanding care at the Trust. The framework comprised of:

  • Defined terms, roles and responsibilities
  • Clearly organised information flows and governance rhythms, structured around the lifecycle of a CQC action – from planning, through to tracking and assurance, through to compliance 
  • Supporting tools including meeting agendas, reporting proformas and decision flow charts

We tested the framework design extensively with the corporate quality team and ensured buy-in from those who would ultimately use it by presenting at the Trust’s Heads of Nursing forum.

CQC action plan template

We built a new CQC action plan template to enable robust action planning and streamlined action tracking – in a consistent way, Trust-wide. We added detailed guidance onto the template and made use of advanced Microsoft Excel functionality to make it as user-friendly as possible. New and innovative features included: columns for outcome metric definitions, targets and data sources; automatically generated and consistent action area ID numbers; status updates of actions based on likelihood of delivery rather than simple snapshots in time. This action plan template underpinned the practical utility of the framework.


The work took on added significance when the CQC carried out an unannounced inspection of the Trust mid-project. Our comprehensive system of sharper action planning and governance – all ultimately aimed at supporting delivery of outstanding care – was therefore able to be used with almost immediate effect.

Following sign-off from a governance group of senior operational staff across the organisation, we handed over the framework to the Trust’s Head of Quality, alongside a list of recommended actions equipping her to implement it effectively.

The value of The PSC’s rigorous and friendly approach shone through in feedback from senior staff at the Trust:

‘I very much welcome the clear approach to this very important work, thank you!’

‘I’ve felt relaxed working with you, and it’s been a really nice experience… We now have a simpler process which I believe will make it easier to be prepared for the CQC.’

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