Recommendation F26: Responsibility for regulating and monitoring compliance
From Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry, published 6 February 2013.
Recommendation
In policing compliance with standards, direct observation of practice, direct interaction with patients, carers and staff, and audit of records should take priority over monitoring and audit of policies and protocols. The regulatory system should retain the capacity to undertake in-depth investigations where these appear to be required.
In brief (written by this site)
The Inquiry recommended that regulators prioritise direct observation, interaction, and record audits over reviewing policies. In commentary of September 2024, published in February 2026, the Department of Health and Social Care (DHSC) and NHS England stated that the Care Quality Commission (CQC) continues to emphasise observation, staff feedback, and care experiences, though the update did not mention record audits or in-depth investigations (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team noted that the government had accepted the recommendation and had reported the introduction of pre-inspection listening events, staff interviews, and time spent with service users (The Thirlwall Inquiry legal team, May 2024).
AI-generated summary of the record on this page, checked by a second model and automatic checks, 1 Oct 2026. The record below is the sources' own words.
About this summary
This recommendation applies across many organisations. The record reflects central policy activity; adoption in individual organisations may vary.
Government response
Accepted.
In A new start – Consultation on changes to the way the Care Quality Commission regulates, inspects and monitors care, the Care Quality Commission consulted on new approaches to inspection which fully reflect this recommendation. On 17 October 2013, it published the responses to the consultation in A new start: Responses to our consultation on changes to the way the Care Quality Commission regulates, inspects and monitors care services, which showed that there is broad agreement with the new approach. It has appointed a Chief Inspector of Hospitals to take the new approaches forward, starting in acute hospitals, but also alongside new Chief Inspectors of General Practice and Adult Social Care, who will extend and develop the approaches for their respective sectors over time. The Deputy Chief Inspector of Mental Health will report to the Chief Inspector of Hospitals on how this applies to mental health services.
The first of new hospitals inspections have already begun, and the Care Quality Commission is reviewing its approach to carrying out investigations in light of its new inspection methodology, the single failure regime and the learning from its report of its own regulatory process at University Hospital of Morecambe Bay.
Through the use of larger inspection teams and longer inspection visits, the Care Quality Commission inspections now include more observation of care and contact with patients and staff. The use of specialist inspectors means a stronger focus on practice and case note review. A key part of the new inspection is to hold ‘listening events’ prior to each inspection to inform the focus of the inspection. The overall focus on quality, rather than regulations, means far less emphasis on checking policies and procedures.
The Care Quality Commission’s large, specialist inspection teams, and their focus on the delivery and experience of services rather than only on compliance with regulations, means that the new inspections are able to include in-depth investigation of individual providers.
The Care Quality Commission also has a specific power of investigation which can cover providers, services across providers, and commissioners. The Care Quality Commission is reviewing its approach to using this power.
How this response relates to the recommendation
Site note: This is volume two of "Hard Truths: The Journey to Putting Patients First" (Cm 8777-II), the government's response to the Inquiry's 290 recommendations, published by the Department of Health on GOV.UK on 19 November 2013 and dated to that day here. The PDF the row links to is the accessible edition, whose title page reads "January 2014". The Department of Health has been the Department of Health and Social Care since January 2018. The volume says it includes accounts from each of the national organisations the recommendations name, but it does not mark which passage each organisation wrote, so every row is filed under the Department that published it.
Blanket government agreement does not establish acceptance or delivery by each addressee. Some response passages cover groups of recommendations.
Scope of the government response
Government responded via "Hard Truths: The Journey to Putting Patients First" (2014), a single document covering all 290 recommendations with a blanket acceptance. Individual recommendation responses were not broken out.
Delivery
DHSC and NHS England say in progress (27 February 2026)
CQC's assessment approach has continued to evolve but the Single Assessment Framework (SAF) continues to emphasize people's experiences of care, observation and feedback from staff and leaders.
Patient safety
The NHS Patient Safety Incident Response Framework has as its first priority the compassionate and effective engagement of those affected by patient safety incidents and the learning response to those incidents. Those affected by incidents must be fully involved in patient safety incident investigations from the start and throughout as long as they wish to be involved.
Site note: DHSC and NHS England's own account of progress, supplied to the Thirlwall Inquiry in September 2024 and printed in the Inquiry legal team's Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues (version dated April 2025, published 27 February 2026). It is not a finding of the Inquiry. Their reviewed extent of implementation reads “Implemented - Ongoing”. Table row: section 18.2 No. 26, PDF page 437.
Department of Health and Social Care says in progress (11 February 2015)
Under the leadership of the Chief Inspectors, the Care Quality Commission has put in place specialist inspection teams that subject providers to greater scrutiny. Inspections now routinely involve expert inspectors and people with experience of receiving care.
The Care Quality Commission inspection teams will hold a public listening event before the start of their site visit or on the evening of the first day. The Care Quality Commission may plan additional listening events depending on the size, geographical spread and demographic profile of the trust. These events are intended for members of the public, so the trust’s management and press are discouraged from attending. The listening events are promoted through appropriate public communications channels, for example, local community group newsletters and local media.
The inspection team will also interview directors of the trust and staff at all levels, at a minimum interviewing the chair, chief executive, medical director, director of nursing, chief operating officer, director of finance, non-executive director responsible for quality/safety, board director responsible for end-of-life care, service leads for the core services and the complaints lead. The inspection team will also hold focus groups and individual interviews including junior doctors, registered nurses and midwives, consultants and other medical staff, student nurses and healthcare assistants, administration and support staff and foundation trust council of governors.
The Care Quality Commission recruits, trains and supports people who use services- known as ‘Experts by Experience’- to accompany its inspection staff on inspections of health and social care services and its visits to monitor the use of the Mental Health Act.
Experts by Experience also attend listening events, consultations and staff training events and take part in activities to develop the Care Quality Commission’s strategy and processes. The Care Quality Commission currently works with around 500 Experts by Experience covering a wide variety of backgrounds.
During inspections, Experts by Experience spend time talking to people who use the service and observing the environment. They have first-hand experience of receiving care so they know which questions to ask to get as much information from the visit as possible. Their findings are used to support the inspector’s judgment on the service and can also be included in the inspection report.
Site note: This is the supporting annex published on 11 February 2015 with "Culture change in the NHS: applying the lessons of the Francis Inquiries" (Cm 9009), attached to the GOV.UK page as "Culture change in the NHS supporting annex". The annex has no title page; that title is GOV.UK's and the PDF's own. Its table has four columns (No., Recommendation, Hard Truths Government response, Progress update), and the row carries the Progress update cell. No column says which organisation wrote an update, so the row is filed under the Department of Health (now the Department of Health and Social Care), which published it.
Site note: The Inquiry addressed this recommendation to the Care Quality Commission, not to the Department of Health. The annex gives this update in the Department's publication and does not say who wrote it, so the row is the Department's report of the progress made on it.
What other bodies have found
In their own words. These do not change the delivery statement above.
Thirlwall Inquiry legal team (15 May 2024)
This recommendation was accepted by the Government.
In the January 2014 Hard Truths report, the Government said that the Care Quality Commission had implemented a new inspection regime, with use of specialist inspectors. These were to include ‘listening events’ prior to each inspection. Inspection teams would interview directors of the trust and staff at all levels, at a minimum interviewing the chair, chief executive, medical director, director of nursing, chief operating officer, director of finance, non-executive director responsible for quality/safety, board director responsible for end-of-life care, service leads for the core services and the complaints lead. There would also be focus groups and individual interviews for junior doctors and other members of staff. During inspections, time would be spent to those who use the service.
Site note: The Thirlwall Inquiry legal team's own notes on implementation, from its Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues (version of 15 May 2024). The review does not colour its Extent of Implementation cell for this recommendation green; it leaves the cell uncoloured where a recommendation was rejected, where evidence of implementation was insufficient, or where steps had been taken but implementation was not yet complete. Table row: section 16.2 No. 26, PDF page 398.
Source
Responsible bodies
Themes and tags
Who has spoken
- Department of Health and Social Care
Response, delivery statement - DHSC and NHS England
Delivery statement - Thirlwall Inquiry legal team
Finding