Sanctions and interventions for non-compliance
Zero tolerance: A service incapable of meeting fundamental standards should not be permitted to continue. Breach should result in regulatory consequences attributable to an organisation in the case of a system failure and to individual accountability where individual professionals are responsible. Where serious harm or death has resulted to a patient as a result of a breach of the fundamental standards, criminal liability should follow and failure to disclose breaches of these standards to the affected patient (or concerned relative) and a regulator should also attract regulatory consequences. Breaches not resulting in actual harm but which have exposed patients to a continuing risk of harm to which they would not otherwise have been exposed should also be regarded as unacceptable.
- The Care Quality Commission (CQC) maintains an enforcement policy and a table of actions for breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (CQC Enforcement Policy, CQC, 2024).
- NHS England stated in April 2025 that the NHS Oversight Framework and the Recovery Support Programme (RSP) are used to manage interventions and support for trusts with significant challenges (DHSC and NHS England implementation update to the Thirlwall Inquiry, April 2025).
- An independent review in October 2024 found that the CQC was "not fit for purpose," citing a backlog of 5,000 notifications of concern and that one in five services had never been rated (Penny Dash Review of the CQC, DHSC, October 2024).
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. See CQC's enforcement policy . CQC publish a table setting out the action they will take if they identify a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. NHS England published the NHS Oversight Framework to ensure the alignment of priorities across the NHS and with wider system partners; identify where ICBs and/or NHS providers may benefit from, or require, support; and provide an objective basis for decisions about when and how NHS England will intervene. These decisions and judgements about support and intervention take into account a range of factors including the organisational and system context and an assessment of leadership and governance. The national Recovery Support Programme (RSP) replaces the previous special measures programmes and will provide a collaborative, ICB-focused approach for supporting those trusts and ICBs with the toughest challenges. ICBs and trusts will get intensive support to use all their levers to address the often complex, historical problems they face, and embed lasting solutions.
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.
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.
Sections 20-21 of the Criminal Justice and Courts Act 2015 (Royal Assent 12 February 2015) created offences of wilful neglect/ill-treatment: Section 20 for individual care workers (max 5 years imprisonment); Section 21 for care provider organisations (unlimited fine). These extended protection beyond mental health and mental capacity contexts to all patients.
View detailed findings
Criminal sanctions for wilful neglect implemented as recommended through the Criminal Justice and Courts Act 2015.
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.