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Health and Care Standards Supporting Guidance

Health and Care Standards

Supporting Guidance

Governance, Leadership and Accountability


What is the Standard about?

This standard sets out expectations for working within a legal and regulatory framework. 

The organisation will have a defined structure in which accountabilities, roles, responsibilities and values are clear and which upholds the standards of behaviour expected of its staff. 

The organisation will have a system of governance which supports successful delivery of its objectives and partnership working.  The organisation will provide leadership and direction so that it delivers effective, high quality and evidenced based services, meets patient needs at pace, with staff that are effective and appropriately trained to meet the needs of patients and carers.

Ensuring that effective systems and processes are in place to assure the organisation, service, patients, service users, carers, regulators and other stakeholders, that the organisation is providing high quality, evidenced based treatment and care through the principles of prudent healthcare and services that are patient and citizen focused.


Who is it for?

All healthcare organisations, departments, services and settings.

In relation to the standard criteria below (in bold) the following key questions need to be considered:

Health services demonstrate effective leadership by setting direction, igniting passion, pace and drive, and developing people.

  • Have you identified and set objectives for your organisation / service which take values and behaviours into account?
  • Do you have mechanisms and systems of assurance in place to ensure your organisation operates in accordance with the Health and Care Standards?
  • Has your Board undertaken an assessment of its effectiveness and developed a prioritised action plan in response?
  • Have you established effective reporting structures for all services?
  • Do you have effective leadership, direction and decision making within your organisation / service?
  • What levels of delegation have been agreed? Do they provide a robust framework for accountability?
  • How do you communicate organisation/service priorities effectively through the organisation, ensuring that these are delivered at pace?
  • Have you identified risks and barriers to achieving these objectives?
  • How do you identify, assess and manage your risks?
  • Do you have a risk framework and a system of assurance?
  • How do you gain assurance about your organisation / service?
  • Have you mapped out your sources of assurance to build an assurance framework?
  • How do you use internal and clinical audit mechanisms to provide assurance?
  • Have you discussed, agreed and communicated clear values and behaviours for your organisation/service?
  • How do you constantly communicate the values and behaviours to staff and the maintenance of high standards and codes of conduct?
  • How do you know your staff are aware of the vision and values of the organisation and the high standards of behaviour and codes of conduct expected of them?
  • Does your Board actively monitor standards of behaviour throughout the organisation?  (This could be via the Audit and Risk Committee, complaints; disciplinary action; or the PADR process)
  • How do you actively promote, embed and robustly support high professional standards and quality requirements and challenge poor behaviour?
  • Do your service priorities, values and behaviours influence your staff development programmes?
  • Does your organisation publish a statement in your Annual Report/ Quality Statement on the adequacy of its arrangements for safeguarding high standards?
  • Does the culture of your organisation support the personal responsibility of individuals in the maintenance of high standards?
  • Is this supported by induction, training, and personal appraisal?
  • What corporate policies exist within your organisation / service to guide your staff and others on how you do business?
  • How do your corporate policies uphold the values of your organisation / service?
  • Do you use patient/user feedback in staff and organisation reviews?


Strategy is set with a focus on outcomes, and choices based on evidence and people insight. The approach is through collaboration building on common purpose.


  • Do you consider the Citizen Centred Governance Principles in developing the organisation’s strategic planning process (IMTPs)?
  • How do you ensure prudent healthcare principles are embedded in your strategies and plans?
  • How do you ensure that your strategies and plans contribute to the strategic vision for health services in Wales?
  • How do you ensure you work in constructive partnership to develop policies and strategies on cross cutting issues and deliver the best outcomes for people?
  • Do you know about all partner organisations / networks?
  • Do you identify and engage with stakeholders and have formal processes in place to capture feedback from stakeholders to inform future strategic planning?
  • Do you involve patients/service users and staff and focus on their needs and experiences, putting them at the heart of strategic plans?
  • How do you ensure that everyone involved in the delivery chain understands each other’s roles and responsibilities and how together they can deliver the best possible outcomes?
  • How do you ensure your business planning procedures effectively prioritise key deliverables to meet your strategic objectives?
  • How do you plan and prioritise resources and evaluate your performance against strategic goals and delivery plans?
  • Do your objectives have specified and measurable outcomes and do you monitor against them?
  • Are you clear about what evidence you need to demonstrate the success of a strategy, and how you will collect this? (outcome focus)
  • What accountability arrangements exist for partnerships and networks?
  • Are you compliant with local compact arrangements between the NHS and Third Sector?
  • Do you communicate evidence and research to teams that develop strategy?
  • Do you communicate this to your teams delivering the service?


Health services innovate and improve delivery, plan resource and prioritise, develop clear roles, responsibilities and delivery models, and manage performance and value for money.


  • How do you ensure your organisation/ service is always learning and look for creative ways and innovation to improve the delivery of services?
  • How do you ensure you work from evidence?
  • How do you empower your staff to innovate and learn to improve quality and service delivery
  • How do you identify and share best practice and benchmark?
  • How is this communicated throughout the organisation?
  • Have you got a clear methodology to prioritise work streams to deliver targets?  Does this relate to resource allocation?
  • Do you use feedback from patients/service users/carers to innovate and change delivery?
  • How do you ensure an understanding of the governance and compliance requirements of regulatory bodies and use feedback from auditors/regulators to inform and improve your business planning processes and procedures?
  • How do you ensure you are using taxpayers’ resource properly and carefully to deliver high quality efficient services?
  • Do you have sound systems of financial control?
  • Do you have clear arrangements for monitoring governance activities?
  • Are all new services / business cases underpinned by the Health and Care Standards?
  • Are your workforce aligned to delivery targets, with clear responsibilities?


Health services foster a culture of learning and self-awareness, and personal and professional integrity.


  • Does your Board/service have a formal improvement process?
  • How do you gain a clear understanding of how well you are performing, what services are doing well, and what service need improving, including services that are carried out by others on your behalf?
  • How do you ensure that you respond quickly and effectively to areas of concern, including those relating to individual performance?
  • How do you invite effective feedback and use the lessons learned to develop and improve the board’s and senior management team’s effectiveness.
  • Do you know about all accreditation and licensing schemes that apply to your organisation and how do you comply with them?
  • How do you ensure your staff comply with their professional standards?
  • Is evidence of CPD required for annual performance and development reviews?
  • What is the feedback and process of reflection from complaints, compliments and incidents?
  • Is there a just/open culture which encourages staff to seek help and advice?
  • What learning programmes are available for staff, and are these aligned to delivery targets, and organisational values and behaviours?


Legislation and Guidance

  1. NHS Wales Governance E Manual
  2. The Corporate Governance Code for Central Government Departments (Until such time as the Welsh Code is issued this sets out the Public Sector Principles of Corporate Governance)
  3. For dental teams see General Dental Council Standards for the Dental Team.



 Academi Wales Model of Capability Self Assessment Framework (tbc)


Good Practice Guides

  1. Annual Quality Statement – How to Guide
  2. Achieving Prudent Healthcare in Wales June 2014
  3. Monitor – Well Led Framework for Governance Reviews – Guidance for NHS Foundation Trusts 2015