Care Quality Commission independence strategy and culture
Consideration should be given to the introduction of a category of nominated board members from representatives of the professions, for example, the Academy of Medical Royal Colleges, a representative of nursing and allied healthcare professionals, and patient representative groups.
- A Care Quality Commission update in February 2026 noted that while the regulator has statutory independence, its operational capacity for inspections more than halved between 2019 and 2024 (CQC Operational Update, February 2026).
- The Penny Dash Review in October 2024 recommended a review of the Care Quality Commission's operational effectiveness and strategic objectives (Review into the operational effectiveness of the Care Quality Commission, Penny Dash, October 2024).
How was this evidence gathered?
Response
Accepted in Part
Response
Accepted in PartThe 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: Partially Implemented - ongoing. The interim Penny Dash Review findings highlighted clear areas where improvement is urgently needed for CQC to be an effective regulator. Interim recommendations included a review of CQC's operational effectiveness linked to how CQC delivers its strategic objectives and regulatory responsibilities. CQC have prioritised the recommendations in the interim report, and this is part of their work to restore trust with the public and providers by listening better, working together more collaboratively and being honest about what they have got wrong. CQC are working at pace and in consultation with their stakeholders to rebuild that trust and become the strong, credible, and effective regulator of health and care services that the public and providers need and deserve. As this work is still ongoing, with additional reviews by Mike Richards and the final Dash Review to still be published, CQC are considering their responses to recommendation 59 alongside this wider piece of work and hope to give a further update in due course.
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.
Francis recommended CQC independence and a strategy distinct from government. CQC has statutory independence but the Dash review (2024) found its operational capacity had declined significantly. Inspections more than halved from 2019-20 to 2023-24. The CQC's own Single Assessment Framework was criticised and is being revised following the Richards review. CQC's regulatory effectiveness is weaker than at its post-Francis peak.
View detailed findings
CQC's independence exists in law but operational capacity has declined significantly since the post-Francis reforms. The regulator is in crisis according to the Dash review.
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.
NMC Revalidation launched 1 April 2016 in direct response to Francis Report. All nurses and midwives must revalidate every three years. Replaced the Post-Registration Education and Practice system. Updated NMC Code published March 2015 strengthened requirements around candour and raising concerns.
NMC published updated Code of Professional Standards for nurses and midwives (March 2015). Standard 14 specifically requires nurses and midwives to be open and candid with all service users about all aspects of care, including when mistakes or harm have occurred.
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.