Well-led · KLOE 4
Governance
Are there clear roles, responsibilities and systems of accountability to support good governance?
CQC wording, mental health care draft, pages 67 to 70.
Draft, not the current assessment framework
CQC's mental health care draft, published March 2026. The current quality statements remain in use.
CQC draft scope
What this proposed KLOE covers
Scope of this key line of enquiry and topic areas include:
- Roles, responsibilities and accountability
- Governance and quality assurance
- Statutory and regulatory requirements
- Robust Mental Health Act oversight (reviewers, SOAD, trends, MHA fact sheets)
- Monitoring use of force
- Clear statutory compliance, including Mental Health Act 2025 implementation
- Shared governance arrangements (where appropriate)
How would this apply to your service?
The draft applies one framework across mental health care, but useful evidence depends on your service and people.
Source: CQC, Mental health care assessment framework, draft, 19 March 2026, pages 67 to 70. Contains public sector information licensed under the Open Government Licence v3.0.
CQC draft rating characteristics
How the draft describes each rating
These are CQC's draft characteristics. CQC says rating characteristics guide judgements, they are not a mechanical checklist.
Outstanding
- Governance arrangements are clear, coherent and continuously tested, enabling effective decision making, accountability and delivery of the service’s strategy. Governance systems are proactively reviewed to ensure they remain fit for purpose, proportionate and responsive to emerging risks, system changes and population needs.
- Governance structures have a clear purpose, give strong oversight, and interact effectively. They are supported by well-defined authority to make decisions, escalation routes and accountabilities. These are consistently understood across the service and routinely tested through real-time issues and learning.
- Governance systems are inclusive and empowering, enabling staff at all levels to identify risks, raise concerns and contribute to improvement. The service demonstrates a learning-focused governance culture, where insight from staff, people who use services and partners informs action and improvement.
- Leaders are assured of the service’s performance through analysis of quantitative data, qualitative insight, audit, lived experience and external assurance. Focus is on patterns, trends and root causes rather than isolated metrics, and this intelligence is used to challenge, learn and improve.
- Governance of partnerships, joint working arrangements and shared services is rigorous and mature, with clear shared objectives, defined accountabilities and joint risk management. The service plays a leading role in the health and care system governance, supporting working collaboratively that delivers improved outcomes across the wider health and care system.
- Governance arrangements explicitly support the delivery of high-quality, safe and equitable care, enabling risks to quality, safety and equity to be identified early and timely, proportionate action to address them. Relevant quality frameworks and recognised standards are implemented effectively and used to reduce inequalities in experience and outcomes.
Good
- There are clear and effective management and accountability arrangements that support the delivery of safe, high-quality and sustainable care These processes are well understood and used to maintain oversight of the service’s performance.
- Managers are values-led and can account for the actions, behaviours and performance of staff. Leaders understand their responsibilities, escalation routes are defined and actions are tracked.
- The board and other levels of governance in the service function effectively and interact with each other appropriately to support delivery of the service’s strategy. Governance structures, roles and responsibilities are understood across the service and are regularly reviewed to maintain fitness for purpose.
- Structures, processes and systems of accountability, including the governance and management of partnerships, joint working arrangements and shared services, are clearly set out, understood and effective. Staff are clear about their roles and accountabilities.
- Governance arrangements support the delivery of safe, effective and equitable care, including implementation of relevant quality frameworks, recognised standards and best practice. Leaders use these frameworks to address known risks and inequalities.
- Leaders implement relevant or mandatory quality frameworks, recognised standards, best practices or equivalents to improve equity in experience and outcomes for people using services and tackle known inequalities.
- Where relevant, there are effective governance, accountability and management arrangements to ensure the legal requirements and duties of any relevant legislation, including the Health and Social Care Act and the Mental Health Act, are complied with.
- Reports from CQC’s Mental Health Act (MHA) reviewers are reviewed by non-executive members, and the board is aware that any required action has been taken to address identified issues. Statistical information on use of the MHA is monitored and patterns of admission and length of stay are considered and compared with national data.
- The board receives reports on the performance of its MHA managers in reviewing detention and on second opinion appointed doctor (SOAD) requests and activity. Action is taken as required. The board makes sure that relationships with stakeholders, such as local authorities and the police, raise issues about MHA 2025 implementation.
- Systems are in place to ensure that data about the use of force is collected, reviewed and submitted to the Mental Health Services Data Set. The executive team or equivalent regularly reviews the data.
Requires improvement
- The governance, management and accountability arrangements are not clear or do not always operate effectively. There has been no recent review of the governance arrangements, strategy, or plans.
- Managers can not routinely account for the actions, behaviours and performance of staff. Workforce planning does not always achieve its purpose, and leaders are reactive to workforce challenges.
- Staff are not always clear about their roles, what they are accountable for, and to whom.
- Cyber security is managed reactively, and there are gaps in maintaining a secure service.
- Where relevant, governance, accountability and management arrangements to ensure the legal requirements and duties of the MHA are complied with, are not always effective or consistently implemented.
- MHA reviewer reports are not routinely reviewed and statistical information on the MHA is not always monitored and compared with national data. There are relationships with stakeholders around the MHA, but they are not formalised to address any issues of implementation.
- Reports on the performance of MHA managers are compiled but not reviewed at board level. SOAD requests and activity are not routinely reported to the board.
- Data on the use of force submitted to the Mental Health Services Data Set is poor quality and not regularly reviewed by the executive team.
Inadequate
- The governance arrangements and their purpose are unclear, and there is a lack of clarity about authority to make decisions and how individual members of staff are held to account. There is no process to review key items such as the strategy, values, objectives, plans or the governance framework.
- Staff and their managers are not clear on their roles or accountabilities. There is a lack of systematic performance management of individual members of staff, or appropriate use of incentives or sanctions.
- Cyber security is not a priority and there are examples of breaches of cyber and data legislation.
- Where relevant, governance, accountability and management arrangements to ensure the legal requirements and duties of the MHA are complied with, are not rigorous or appropriate.
- The board does not review Mental Health Act reviewer reports.
- Information relevant to monitoring the use of the MHA, including performance of MHA managers and SOAD activity, is not collected consistently, not reviewed appropriately or action is not taken as a result.
- Data about the use of force is not consistently collected and/or submitted to the Mental Health Services Data Set.
Want to know how your service would fare?
Book a mock inspection run against the draft KLOEs, or call 020 8090 5346 to speak to one of our experts.