CQC “Well-led” evidence pack: what to show, how to structure it (Single Assessment Framework)

If you’re preparing for a CQC visit, “Well-led” is one of the five key questions CQC uses to assess services (Safe, Effective, Caring, Responsive, Well-led).

Under the Single Assessment Framework (SAF), Well-led is assessed using seven quality statements.

This guide shows a practical, inspection-ready way to build a Well-led evidence pack so you can quickly find the right proof, show impact, and keep it current.

What CQC means by “Well-led” (SAF quality statements)

CQC’s Single Assessment Framework sets out seven Well-led quality statements:

• Shared direction and culture

• Capable, compassionate and inclusive leaders

• Freedom to speak up

• Workforce equality, diversity and inclusion

• Governance, management and sustainability

• Partnerships and communities

• Learning, improvement and innovation

Inspection tip: Organise your evidence pack using these headings. It maps directly to how inspectors structure and record their findings.

The 6 evidence categories CQC uses (build your pack to match)

CQC groups evidence into six categories, which inspectors then triangulate:

1. People’s experience of health and care services

2. Feedback from staff and leaders

3. Feedback from partners

4. Observation (e.g. how leadership, culture and challenge are seen in practice)

5. Processes

6. Outcomes

How to use this:
For each Well-led quality statement, store at least one item from multiple evidence categories. Policies alone are not enough.

Why governance proof matters (Regulation 17)

CQC’s guidance on Regulation 17 (Good governance) requires providers to have systems and processes that:

• Assess, monitor and improve quality and safety

• Identify, assess, monitor and mitigate risks

• Continually evaluate and improve governance and auditing practice

This means governance records (audits, actions, risks, learning and oversight) are central to a strong Well-led rating — not optional extras.

The “Well-led evidence pack” structure

7 folders aligned to the SAF (and what to put in each)

1) Shared direction and culture

This quality statement focuses on having a shared vision, strategy and culture, and how this links to inclusion, engagement and understanding people’s needs.

Add these:

• Vision, values or strategy (1–2 pages, plain English)

• How staff learn and revisit the vision (induction slides, briefings)

• “You said, we did” examples from people using services or relatives

Best evidence categories: People’s experience, staff feedback, outcomes.

2) Capable, compassionate and inclusive leaders

This is about leadership capacity, behaviour and support, not job titles.

Add these:

• Leadership roles and responsibilities (who owns what)

• Supervision and appraisal schedule + completion snapshot

• Clear support and escalation pathways (how concerns are managed)

3) Freedom to speak up

CQC looks for a culture where people feel safe to raise concerns and believe they will be acted on.

Add these:

• Whistleblowing policy + how staff access it

• Staff meeting minutes showing concerns raised and actions taken

• Anonymous feedback results and follow-up actions

Best evidence categories: Staff feedback, processes, outcomes.

4) Workforce equality, diversity and inclusion

This is about fairness in practice, not just policy.

Add these:

• Equality policy and how it’s applied in recruitment and development

• Examples of how barriers are identified and addressed (keep confidential data secure)

• Evidence of fair access to training, supervision and progression

5) Governance, management and sustainability

(your inspection engine)

Anchor this section clearly to Regulation 17 requirements.

Minimum evidence set:

• Governance calendar (weekly / monthly / quarterly reviews)

• Audit schedule + most recent completed audits (with findings)

• Action plan tracker (owner, due date, status, completion evidence)

• Risk register (top risks, controls, review dates)

• Provider or management meeting minutes showing oversight and challenge

Environmental sustainability (proportionate):

• Named lead or governance oversight

• Policy or statement showing how environmental risks are considered

• Evidence of discussion or action appropriate to the service

Make it inspection-friendly:
Place a 1-page Governance Summary at the front:

• Top 3 current risks and mitigations

• Most recent audits and key findings

• Open actions over 30 / 60 / 90 days

6) Partnerships and communities

Inspectors focus less on meetings attended and more on impact.

Add these:

• How you work with key partners relevant to your service

• Examples of coordinated care improvements (what changed, why, results)

• Shared learning outcomes (e.g. safeguarding partnership learning)

Best evidence categories: Partner feedback, outcomes, processes.

7) Learning, improvement and innovation

This section proves you learn, improve, and embed change.

Add these:

• 3–5 short “learning loops” (one page each):

  • Issue → investigation → action → review → improvement

• Evidence the change stuck (audit re-check, observation, outcome trends)

• Improvements driven by feedback from people using services, staff or partners

A simple index page that inspectors love

Create a front page showing:

• Quality statement (all 7)

• Where evidence is stored (folder or link)

• Owner (named role/person)

• Last updated date

• Key items inside (3–6 bullets)

• Linked evidence categories

This turns a pile of documents into a navigable, inspection-ready pack.

Common mistakes that weaken a Well-led pack

• Policies with no evidence of use or impact

• Issues logged but no review or improvement shown

• Out-of-date audits, action plans or risk registers

• Evidence limited to one category instead of triangulation

Final thought

A strong Well-led evidence pack doesn’t need to be large — it needs to be current, structured, and used. If you can show how leadership decisions translate into safer care, learning and improvement, inspectors can see it quickly.

Want to make your Well-led evidence easier to manage?

Preparing a Well-led evidence pack is much simpler when your policies, audits, actions and governance records are all in one place.

CareAdmin helps providers:

• Keep policies, audits and action plans up to date

• Track ownership, review dates and evidence of completion

• Quickly find the right evidence during a CQC inspection

If you want to see how this could work for your service, you can book a short demo to explore how CareAdmin supports CQC inspection readiness without adding unnecessary admin.

Book a demo and see CareAdmin in action