Literature review
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Improvement cultures in health and adult social care settings

A rapid literature review for the Care Quality Commission
Health services planning Organisational culture Quality management Monitoring and evaluation Behavioural insights Regulatory culture Health Public health evaluation England

The Care Quality Commission (CQC) is the independent regulator of health and social care in England. In 2021 CQC published a new strategy for the changing world of health and social care. The strategy aims to make regulation more relevant to the way care is now delivered, more flexible to managing risk and uncertainty, and enable CQC to respond more quickly and proportionately as the health and care environment evolves. It also outlined CQC’s desire to promote improvement cultures across health and social care, highlighting the importance of culture in driving improvements in safety and quality.

To support the delivery of their strategy, CQC commissioned SQW (in partnership with the Kings Fund Library Service) to deliver a rapid literature review, focusing on improvement cultures in health and adult social care. The review aimed to inform CQC’s approach to assessing and encouraging improvement, improvement cultures and improvement capabilities of services, while strengthening CQC’s regulatory role.

Findings: Regulatory functions

  • Viewing improvement holistically is important. Various elements of ‘good’ culture need to be in place to achieve and sustain improvement.
  • Both espoused and ‘lived’ culture are key. Disconnect between espoused and experienced culture may (but not always) indicate disfunction.
  • The evidence highlights the importance of sub-cultures. Exploring cultures at different levels in a setting is likely to prove key.
  • CQC may wish to assess and inspect for evidence of an environment where people feel they can speak up and that their voice will be heard.
  • It is important to monitor and assess how services capture and use people's voices.
  • Training and supporting people to be involved in service improvement activities is an enabler. CQC may have a role to play in sharing examples of good practice. CQC could also inspect and assess for this.
  • CQC may wish to consider how their assessment process captures evidence of staff empowerment and influence. CQC could consider sharing examples of good practice.
  • Developing an improvement culture takes time. Ensuring realistic expectations, including identifying expected interim outcomes, may prove useful. A logic model or theory of change could support this.
  • Wider factors can support or inhibit improvement. Understanding the context can help to understand an organisation’s culture. It also may enable CQC to further support settings.
  • Leaders have a key role in enabling improvement. Leaders are not always those in leadership roles. Identifying the extent to which leaders recognise and act on this may prove useful.


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