Governance and assurance - ibex gale
Governance reviews, CQC Well-led support, regulatory assessment and due diligence

We support health and social care organisations to achieve good governance as required by the CQC.

Our governance and assurance team has extensive legal experience advising the health and social care sector on risk and compliance, and so are uniquely placed to support health and social care providers in identifying regulatory risks, compliance gaps and governance shortfalls, and crafting solutions to deliver Board assurance.

We work with organisations supporting the establishment and development of good clinical governance across the wider organisation to ensure visibility from ‘Ward to Board’. Our methodology for data gathering includes interviews, document review and analysis, listening groups and surveys.

Our reviews include consideration of Board awareness of quality and safety issues, effectiveness of quality and safety committees and sub-groups, effectiveness of quality and safety reporting structures within the organisation and compliance with the regulatory framework and internal procedures and processes.

We will work closely with you to in relation to the outcomes of the review and support the implementation of any recommendations.

CQC Well-Led Support


Whether a health or social care organisation is ‘Well-led’ is now the key focus of CQC inspections as it’s generally accepted that if an organisation has the right leadership and culture in place, good outcomes in the other domains i.e. Safe, Effective, Responsive and Caring, are likely to follow.

The CQC define ‘Well-led’ as ʻBy well-led, we mean that the leadership, management and governance of the organisation assures the delivery of high quality, person-centred care, supports learning and innovation, and promotes an open and fair culture.ʼ


Demonstrating to the CQC that your organisation is ‘Well-led’ will increase the CQCʼs confidence in you as provider (and thereby reduce the frequency of the CQCʼs scrutiny) and is the route to obtaining ʻGoodʼ and ʻOutstandingʼ inspection ratings.

The key to maximising an organisationʼs chances of obtaining a positive rating in the ‘Well-led’ domain is to ensure that relevant team members who are likely to be interviewed by the CQC are thoroughly prepared and knowledgeable regarding the issues facing the organisation.

We can assist with this by:

– Delivering Board/Senior Management level training on ‘Well-led’ including what to expect at a CQC inspection and key areas of concern/focus for the CQC.

– Mock ‘Well-led’ interviews with senior individuals who are likely to be interviewed by the CQC.

– ‘Well-led’ compliance/gap analysis report based upon the outcomes of the ‘Well-led’ interviews, with reference to the CQC’s ‘Well-led’ assessment framework.

– Production of a quick reference well-led handbook containing the key information that the CQC will expect leaders to know about their organisation.



Culture Review Outcomes: Regulatory Analysis and Assessment


We work closely with our Organisational Culture  specialists to provide expert regulatory analysis and assessment following the completion of in-depth culture reviews.

We analyse the findings from a culture review and identify any potential risks of non-compliance with an organisation’s CQC regulatory requirements and healthcare practitioners’ professional obligations (i.e. GMC/NMC codes of conduct).

Our analysis includes an assessment of the potential impact of the findings on CQC’s rating of the relevant service and or wider organisation, together with tangible actions for the client to take to mitigate the risk of rating downgrades.

Health and Social Care Due Diligence 


We have significant experience in undertaking and project managing comprehensive regulatory due diligence exercises on mergers, acquisitions and sales of health and social care businesses, and producing regulatory due diligence reports highlighting key areas of health or social care regulatory risk for UK and international clients.

We can offer a stand-alone regulatory due diligence service or work alongside your corporate legal team to input our specific health and social care regulatory expertise into the wider due diligence exercise.

We can also support UK and overseas public and private health and social care organisations, on the regulatory implications of acquiring or selling health or social care businesses in the UK.

Sarah Dobson leads our governance and assurance work, supported by Kimberley Fradley

Please get in touch via our contact us form and one of our team will be in touch. 

Frequently Asked Question
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