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F50

Enhancement of monitoring and the importance of inspection

Mid Staffs Inquiry · Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry · Issued 6 February 2013 · Addressed to: CQC

Government responseDepartment of Health and Social Care: Accepted (Nov 2013)

DeliveryDHSC and NHS England say partially delivered (Feb 2026)Department of Health and Social Care says in progress (Feb 2015)

Recommendation, verbatim from the inquiry

●Inquiry recommendation

The Care Quality Commission should retain an emphasis on inspection as a central method of monitoring non-compliance.

Mid Staffs Inquiry, Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry · 6 Feb 2013 Source PDF →

Published evidence summary

AI-generated evidence summary

In commentary from September 2024 published in February 2026, the Department of Health and Social Care and NHS England reported that the Care Quality Commission gathers evidence both on site and off site, maintaining on-site observation to assess care quality (DHSC and NHS England, Feb 2026). They stated that the commission carries out on-site activity more frequently where services present greater risks of undetected poor culture or where concerns exist regarding transparent evidence (DHSC and NHS England, Feb 2026). Previously, in May 2024, the Thirlwall Inquiry legal team noted that the government had accepted the recommendation and highlighted the commission's specialist inspection regime (The Thirlwall Inquiry legal team, May 2024).

AI-generated summary of the record on this page, checked by a second model and automatic checks, 26 Sep 2026.

Report-level response context

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.

Government response

●Department of Health and Social Care · Accepted · 19 Nov 2013

Speaker not recorded. Source: Department of Health, Hard Truths: the Journey to Putting Patients First, volume 2 (Cm 8777-II), November 2013

Accepted.
The Care Quality Commission has introduced a fundamentally different and strengthened approach to inspection as the centrepiece of how it assures standards of care.
The Care Quality Commission’s new approach to inspection involves large teams of specialists and public listening events, resulting in judgements about the quality of care rather than compliance with regulations. The new approach is led by the Chief Inspector of Hospitals, Professor Sir Mike Richards; several thousand specialists and members of the public have put themselves forward to join his inspection teams. This level of engagement, and the more relevant outputs, ensures that inspection is at the heart of the Care Quality Commission’s role and purpose. The new approach is designed to support inspection by specialist teams, through inspections which, rather than being focused on regulations, are based on identifying lines of enquiry from whatever quantitative and qualitative information suggest about standards of care.
The Care Quality Commission’s new approach to monitoring the quality and safety of services has been introduced initially in acute hospitals. New Chief Inspectors of General Practice and of Adult Social Care took up post in October 2013, and will now spearhead the extension and development of new approaches to monitoring and inspecting standards of care in those sectors. The Deputy Chief Inspector of Mental Health will report to the Chief Inspector of Hospitals on how this applies to mental health services.

Extract from: Hard Truths: The Journey to Putting Patients First. Volume Two of the Government Response to the Mid Staffordshire NHS Foundation Trust Public Inquiry: Response to the Inquiry's Recommendations

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.

Delivery

●DHSC and NHS England say partially delivered · 27 Feb 2026

In the CQC’s new assessment methodology, the CQC gather evidence both on site and off site. Observing care and the care environment remains an important way to assess quality and spend time on site: -observing care and how staff interact with people -observing the care environment, including equipment and premises -talking with people using the service -talking with staff and leaders

CQC will carry out on-site activity more frequently in settings where: -there is greater risk of a poor or closed culture going undetected in a service -it is the best way to gather people's experience of care -we have concerns about transparency and availability of evidence -we have a statutory obligation to do so

Please also see response to recommendation 55 in relation to the Dash Review.

From: The Thirlwall Inquiry: Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues (version dated April 2025)

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 “Partially implemented – Ongoing”. Table row: section 18.2 No. 50, PDF page 451.

●Department of Health and Social Care says in progress · 11 Feb 2015

As described in recommendation 38, the Care Quality Commission started piloting its new inspection regime in September 2013 and has been steadily rolling this out to all health and care sectors. Care Quality Commission is now in the process of inspecting all NHS acute trusts using the new model of inspection

From: Culture Change in the NHS supporting Annex (annex to Culture change in the NHS: applying the lessons of the Francis Inquiries)

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 referred to the Care Quality Commission’s new inspection regime, which was said to involve large teams of specialists and public listening events, with a focus on quality of care rather than complained with regulations.

From: The Thirlwall Inquiry: Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues (version of 15 May 2024)

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. 50, PDF page 414-415.

How this page is built

The recommendation and the government responses are verbatim from primary documents. Delivery statements and other bodies' findings are shown in their own words, each with its source. The summary is written by this site and labelled as such. The Index does not paraphrase sources or characterise intent; it records what has been published.