Well-led evidence pack

How to read this page

QS codes first: We name the exact Quality Statement (e.g., SAFE3, EFFECTIVE1).
Evidence artefacts: Screenshots/exports you can attach to assessments.
Inspector prompts: Language inspectors use when requesting proof.

SAF alignment (highlights)

SAFE3: Escalation thresholds + conflicting guidance visible.
SAFE1: Recommendation-level change detection and history.
SAFE6 (indirect): Role-specific views with escalation cues.
EFFECTIVE1: NG/SIGN citations with last-checked dates.
EFFECTIVE2: Audit measures derived from thresholds.

QS-coded view of the Single Assessment Framework

Use the codes first, then the artefact, then the date checked

SAFE

SAFE1 – Learning culture: Change detection log + review note

SAFE3 – Safe systems: Threshold screenshots + conflict visibility

SAFE6 – Safe staffing: Role-based view showing escalation prompts

Inspector asks: "Show how staff see the right threshold and when it changed."

Evidence to attach: Version-locked export, dated screenshot, update log.

EFFECTIVE

EFFECTIVE1 – Evidence-based care: NG/SIGN citations with last-checked date

EFFECTIVE2 – Monitoring outcomes: Audit standard derived from thresholds

Inspector asks: "Where is the evidence practice matches current guidance, and how do you audit it?"

Evidence to attach: Export with citations + an audit measure tied to QS code.

RESPONSIVE

RESPONSIVE1 – Equity and access: Time-critical vs urgent pathways

RESPONSIVE2 – Planning and delivery: Update alert + pathway change note

Inspector asks: "Show how you route urgent needs and update plans when guidance changes."

Evidence to attach: Alert log + revised pathway screenshot.

WELL-LED

WELLLED1 – Governance: Version-locked export with meeting minute reference

WELLLED2 – Learning and improvement: Change impact summary with QI link

WELLLED3 – Information governance: Provenance statement + update cadence

Inspector asks: "Show the record of what guidance was used for this decision and how you assured its provenance."

Evidence to attach: Snapshot PDF, provenance note, last-check date.

Mapping NICE Guidance Types to CQC Quality Statements

Understanding which NICE products support which CQC domains

NICE Type	Primary CQC Domains	Typical Use
NG (NICE Guidelines)	Effective, Safe	Clinical standards, policies, audits
QS (Quality Standards)	Effective, Well-led	Audit measures, QI projects
TA (Technology Appraisals)	Effective, Responsive, Well-led	Access, funding, compliance

NICE NG for SAFE

How it supports SAFE: Defines safe clinical practice, risk mitigation, IPC, and medicines safety.

Inspector lens: "Show us guidance that reduces risk and prevents harm."

NICE NG for EFFECTIVE

How it supports EFFECTIVE: Primary evidence for evidence-based care delivery.

Key rule: NG = what good care is; QS = how well it's delivered

NICE QS for WELL-LED

How it supports WELL-LED: Framework for audit, QI and governance assurance.

Inspector lens: "How do leaders know care is aligned with national guidance?"

What inspectors usually ask for

Reference the QS code, the artefact, and the last-checked date in your answer

EFFECTIVE1 & EFFECTIVE2

Language to use: "Evidence for EFFECTIVE1 – Delivering evidence-based care" / "EFFECTIVE2 – Monitoring outcomes"

Artefacts that land well:

Export showing NG/SIGN citations + last checked date
Audit measure derived from CliniSearch threshold extraction
Protocol page with superseded flag and replacement recommendation
Outcome dashboard tagged with QS code

Red flag: Using superseded guidance without documented justification

WELLLED1 & WELLLED2

Language to use: "Evidence for WELLLED1 – Governance, management and oversight" / "WELLLED2 – Learning and improvement"

Artefacts that land well:

Version-locked export appended to meeting papers
Change impact note tied to a QI cycle
Deviation log with governance approval and review date
Update review cadence with owners and dates

Red flag: No documented process for reviewing NICE updates

Self-assessment phrases

Inspection-ready language:

"Supports evidence for EFFECTIVE1 via NGxxx, last checked 12 Dec 2025"
"QI project measured performance against QSxxx; see audit extract dated 10 Dec 2025"
"Access to treatment followed NICE TAxxx; deviation log entry DL-07 approved 01 Nov 2025"

Avoid: "NICE mandates...", "NICE requires..." (NICE recommends, it doesn't mandate)

Explaining Deviations from NICE Guidance

When local practice diverges:

Document the rationale clearly
Show governance approval process
Demonstrate patient safety consideration
Evidence regular review of the deviation

Key phrase: "Deviation approved by [governance body] on [date] with review scheduled [date]"

Common CQC Inspection Weaknesses

NICE-related issues that trigger follow-up during inspections

Inspection-Ready Documentation Framework

Building evidence packs that satisfy CQC expectations

CQC Alignment Box Template

Add this to all audit/QI documentation:

CQC Alignment:

Supports evidence for [Domain] → [Quality Statement]

Example: Supports evidence for Effective → Using evidence-based guidance (QS 10)

For Audit Programmes

Map each audit to specific CQC Quality Statements
Document NICE guidance version and review date
Include update review process in audit protocol
Show governance approval for audit standards
Demonstrate closure of audit loops with outcome data

For Board Assurance

Systematic NICE guidance review schedule
Gap analysis: current practice vs NICE recommendations
Approved deviation register with review dates
TA implementation tracker (mandatory guidance)
Quality dashboard showing QS compliance

For CQC Self-Assessments

List key NICE guidance informing each domain
Reference audit evidence demonstrating compliance
Explain any deviations with governance approval
Show staff training on relevant NICE guidance
Demonstrate outcome monitoring and improvement

For Inspection Evidence Packs

Index of NICE guidance by CQC domain
Audit reports with CQC alignment noted
Governance meeting minutes showing NICE review
Staff competency framework linked to NICE
Patient outcome data mapped to quality standards

System capabilities that support this evidence

Features that operationalise CQC alignment inside CliniSearch.

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