Responsibility for regulating and monitoring compliance
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.
- The Penny Dash Review in October 2024 found that the CQC's inspection methodology had lost credibility and that the lack of specialist expertise hindered effective regulation (Review into the operational effectiveness of the Care Quality Commission, DHSC, October 2024).
- The NHS Patient Safety Incident Response Framework (PSIRF) requires the engagement of those affected by incidents in the learning response (DHSC and NHS England implementation update provided to the Thirlwall Inquiry, April 2025).
- No further published evidence has been identified since February 2026.
How was this evidence gathered?
Response
Accepted
Response
AcceptedThe government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" in March 2013. Key reforms included a new Chief Inspector of Hospitals, strengthened Care Quality Commission inspection regime, a statutory duty of candour, and the fit and proper person test for NHS directors. Volume 2 (Cm 8754) contains the government's detailed responses to each of the 290 recommendations. See: https://assets.publishing.service.gov.uk/media/5a7cd486ed915d63cc65d167/34658_Cm_8777_Vol_1_accessible.pdf
Progress Timeline
DHSC and NHS England implementation update provided to the Thirlwall Inquiry (April 2025). This is the government's own account of progress, submitted to the inquiry. Reviewed extent of implementation: Implemented - Ongoing. 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.
Published Evidence
Published assessments of progress from inspectorates, select committees, official progress reports, and other sources. Source type badge indicates whether each assessment is independent or government self-reported.
CQC was fundamentally reformed after Francis: Sir Mike Richards appointed as first Chief Inspector of Hospitals (2013); new inspection methodology with large teams, specialist experts, unannounced visits; ratings system introduced (Outstanding/Good/Requires Improvement/Inadequate). However, the Penny Dash review (October 2024) found CQC had 'lost credibility' -- inspections dropped from 15,800 in 2019-20 to 6,700 in 2023-24; 500 unpublished inspection reports; registration backlogs. The Single Assessment Framework was criticised for vague language. The regulator reformed after Francis has itself become the subject of a highly critical review.
View detailed findings
CQC underwent substantial reform in 2013-2017 but operational capacity has since declined. The Dash review found it had lost credibility. Institutional reform has not been sustained.
Penny Dash Review (commissioned May 2024) found significant failings at CQC. Health Secretary declared CQC "not fit for purpose". Key findings: one in five services never rated; inspection levels well below pre-pandemic levels; lack of specialist inspector expertise; 5,000 notification-of-concern backlog. CQC consulting on resetting its approach from October 2025.
Research published 2023 marking ten years since the Francis Report found mixed results. Structural and legislative changes largely delivered (duty of candour, FPPR, CQC overhaul, revalidation, Freedom to Speak Up Guardians). However, cultural change not fully embedded; understaffing, fear of speaking up, and poor complaint handling persist in parts of the NHS.
Monitor merged with the Trust Development Authority to form NHS Improvement from 1 April 2016. NHS Improvement then merged with NHS England from 1 July 2022 under Health and Care Act 2022. Francis recommended incremental merger of system regulatory functions between Monitor and CQC; this was partially achieved through structural reorganisation.
Government published "Culture Change in the NHS" (Cm 9009) reporting progress on all 290 recommendations. Key achievements: 19 hospitals placed in special measures; those trusts recruited 109 additional doctors and 1,805 additional nurses; 129 board-level changes made; excess avoidable deaths fell by 450 in less than a year.
New "Fundamental Standards" replaced previous CQC registration requirements from 7 November 2014. Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 introduced clearer minimum standards including: person-centred care (Reg 9), dignity (Reg 10), safe care (Reg 12), staffing (Reg 18), good governance (Reg 17), fit and proper persons (Reg 5), duty of candour (Reg 20).
CQC overhauled its inspection regime in response to Francis. Professor Sir Mike Richards appointed as first Chief Inspector of Hospitals (July 2013). New methodology based on five key questions (Safe, Effective, Caring, Responsive, Well-led) rolled out nationally October 2014. Four-tier ratings introduced (Outstanding/Good/Requires Improvement/Inadequate). Specialist expert-led inspection teams replaced generalist compliance model.
Government published "Hard Truths: The Journey to Putting Patients First" (Cm 8777) in two volumes. Vol 1 set out new actions; Vol 2 provided detailed response to each of the 290 recommendations. Approximately 204 of 290 recommendations were fully accepted.