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The life of a CQC action

It might not be the latest blockbuster biopic, but following the lifecycle of an individual Care Quality Commission action is a useful approach to develop a planning and governance framework.

It’s been a year since we supported South London and Maudsley NHS Foundation Trust to evaluate and design improvements to its Care Quality Commission (CQC) action planning and governance processes.

We’ve been reflecting on what aspects of this work most resonated with us and with our client, and hope that they might resonate with other readers too.

The life of a CQC action

Read more about our work with South London and Maudsley NHS Foundation last year here. 


The lifecycle of a CQC action

We know that frameworks for action planning and tracking aren’t the most thrilling of subjects. They’re critical for robust governance, but don’t get the glamour they might deserve.

Mindful of this, we livened things up by designing the framework to revolve around the idea of an individual CQC action and its lifecycle – specifically, the three phases that an action progresses through over time:

  • Action planning
  • Action tracking & assurance
  • Action compliance


While the royalties for a compelling new biographical film or catchy animation based on the life of a CQC action might take some time to roll in, we found that this approach to developing a framework was effective because:

  • It made the framework easier to engage with and explain
  • It kept the focus on the tangible CQC actions themselves; the accompanying processes, information flows and tools were the means to support effective delivery and ensure that actions stuck
  • It helped us consider the fully rounded journey that the framework needed to provide for individual actions and action owners – e.g. the third phase of “compliance” might otherwise have been overlooked: how to treat actions that had been signed off as complete but needed periodic checks for ongoing compliance


Co-design with Trust colleagues

We engaged early with nursing and quality leads from each of the Trust’s directorates. The purpose of this was to test our early thinking on the ideal future state for CQC action planning and governance, to ascertain how aligned current processes were with this future state, and to ask colleagues about specific pain points which the new framework should address. For example, we heard that the current online repository for saving documentary evidence of progress against actions wasn’t fit-for-purpose – so we considered a new option and included this in our recommendations. Towards the end of our support, we presented the framework back to this group, and showed clearly where we had incorporated their input.

We also worked closely throughout with the Trust’s Deputy Director of Nursing and Head of Quality. Meeting twice a week and co-designing the framework with them meant that we could ensure alignment with the Trust’s corporate requirements and ensure Trust ownership of the work beyond our involvement. We were delighted to receive feedback from these colleagues that they’d enjoyed collaborating with us and that they had confidence in this simpler process which would make it easier to be prepared for the CQC.

The CQC’s recent announcement at the start of February indicated that it will be increasing the volume of its risk-based inspections and ongoing monitoring activities, in light of reduced pressures from Covid. We believe that other providers – spanning acute physical health, mental health and community services – could benefit from developing a similarly robust action planning and governance framework.


If your organisation is interested in finding out more about how we could support you, please get in touch with Chris Bradley, Senior Partner, at

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