Guidance for NHS trusts and foundation trusts: assessing the well-led key question

Page last updated: 8 April 2024

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Shared direction and culture

We have a shared vision, strategy and culture. This is based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and our communities in order to meet these.

What does good look like

The trust has an aspirational vision and a statement of values, with a realistic strategy and robust plan for delivery with clear objectives and timescales. These have been produced together with people who use the trust’s services, staff and system partners. The strategy is based on a clear understanding of:

  • quality of care
  • improvement
  • finances
  • operational performance.

It explicitly addresses challenges for workforce, estates, procurement, and information technology. It is clear which leader is responsible and accountable for delivering each component of the trust’s strategy and delivery plan.

The trust’s strategy and plan considers the wider local and national context, and is aligned to the strategies and plans of relevant integrated care partnerships, health and wellbeing boards, integrated care boards, place-based partnerships, and provider collaboratives. This is to ensure that services are high quality and planned to meet the needs of relevant population groups. There are joint strategies and plans with relevant integrated care boards and, where appropriate, other key system partners.

The trust transparently monitors and reviews how it delivers its objectives. This is supported by effective governance structures and clear systems of accountability at all levels. These structures support multidisciplinary, integrated working and effective risk mitigation and management.

The trust understands the challenges to delivering the strategy, including relevant local health and care system factors. It has a realistic action plan to address them.

Staff feel positive and proud to work in the trust. They understand the vision, values and strategic goals and their role in achieving them. Most staff are aware of, and demonstrate, the vision and values of the trust. Staff understand the importance of equality and human rights in their work and the factors that can lead to closed cultures.

Delivering for patients and communities and tackling health inequalities is at the heart of the trust’s ways of working. Compassion is shown at all levels within the organisation and with people who use services. The trust has a strong emphasis on the safety and wellbeing of staff. There is a culture of collaboration, openness, integrity, respect, and collective responsibility. Staff have co-operative, supportive and appreciative relationships, and teams and system partners come together quickly to resolve conflicts constructively.

The trust has mechanisms to identify and address behaviours that are inconsistent with the values of the NHS. These enable staff to raise concerns without fear of reprisal or repercussions.


Further detail and context:

Strategy and planning

Developing a realistic and robust strategy and plan delivers significant benefits for trusts. It sets the direction and informs how trusts develop to enable them to provide high-quality care. Strategic planning at relevant points will guide decisions on how to provide services and allocate resources. This will help executives and non-executives to govern effectively.

Organisational culture

The culture of trusts is crucial to ensuring they deliver high-quality, safe and effective care. Positive cultures and working environments also have a positive impact on the wellbeing of and engagement with staff.

Safety culture

A positive organisational culture supports safety for staff and patients. Safety culture is one of 2 key foundations of the NHS Patient Safety Strategy, supported by the Patient Safety Specialist role and Patient Safety Partners. A positive safety culture is one where the environment is collaboratively crafted, created, and nurtured so that everybody (individual staff, teams, patients, families, and carers) can flourish. This ensures quality, safe care through continuous learning and improvement of safety risks, supportive, psychologically safe teamwork; and enabling and empowering everybody to speak up.

Treating staff fairly supports a culture of fairness, openness and learning in the NHS by making staff feel confident to speak up when things go wrong, rather than fearing blame. Supporting staff to be open about mistakes allows valuable lessons to be learned so the same errors can be prevented from being repeated.


Best practice / guidance

Strategy and planning

NHS England: Good Governance and Collaboration

NHS England: Guidance on developing the joint forward plan

National Quality Board: Shared Commitment to Quality

Resources on culture

Guidance: The NHS Constitution for England

CQC: Learning, candour and accountability

Nursing & Midwifery Council: Openness and honesty when things go wrong: the professional duty of candour

NHS England: The Culture and Leadership programme

NHS England: We are a team

NHS England: Staff Health and Wellbeing Framework

NHS England: Civility and Respect

NHS England: Growing occupational health and wellbeing together

CQC: Our work on closed cultures

Resources on safety culture

NHS England: Safety culture: learning from best practice

NHS England: The NHS Patient Safety Strategy (2019)

NHS England: A Just Culture Guide


Link to regulations

Regulation 10: Dignity and respect

Regulation 12: Safe care and treatment

Regulation 17: Good governance

May also consider: Regulation 9: Person-centred care