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 in progress (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 develop a specialist cadre of inspectors by thorough training in the principles of hospital care. Inspections of NHS hospital care providers should be led by such inspectors who should have the support of a team, including service user representatives, clinicians and any other specialism necessary because of particular concerns. Consideration should be given to applying the same principle to the independent sector, as well as to the NHS.
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 February 2026, the Department of Health and Social Care and NHS England reported that the Care Quality Commission retains specialist inspectors across hospitals, mental health, primary care, and adult social care within regional integrated assessment and inspection teams, while internal work reviewing the split between inspectors and assessors remains ongoing (DHSC and NHS England, Feb 2026). Previously, in May 2024, the Thirlwall Inquiry legal team recorded that the government had accepted the recommendation and noted the introduction of three Chief Inspector roles alongside multidisciplinary inspection teams (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 response
●Department of Health and Social Care · Accepted · 19 Nov 2013
Accepted.
The Chief Inspector of Hospitals has begun inspecting in this way. Useful lessons were learnt from the Care Quality Commission’s targeted inspections of 150 learning disability in-patient units following events at Winterbourne View hospital; these benefitted enormously from the involvement in inspection of trained and supported learning disabled self-advocates and family carers.
Also, building on the approach developed by Professor Sir Bruce Keogh’s reviews of mortality in 14 NHS trusts, the Chief Inspector of Hospitals has started inspections involving teams made up of senior and junior doctors, nurses and allied health professionals; senior managers; and people with experience of using hospital services. Six thousand individuals put themselves forward to be part of these inspections, and the number continues to increase. This is encouraging progress towards ensuring that inspection teams with a range of specialist and lay perspectives will be sustainable.
Through its Chief Inspector of Hospitals, the Care Quality Commission will extend this approach to mental health, community healthcare and ambulance services during 2014–15, with appropriate adaptation and tailoring to those sectors. The approach will be adapted to independent as well as NHS providers.
New Chief Inspectors of General Practice and of Adult Social Care took up post in October 2013, and will similarly spearhead the extension and development of new approaches to monitoring and inspecting standards of care in those sectors.
Delivery
●DHSC and NHS England say in progress · 27 Feb 2026
CQC retain specialist inspectors in hospitals, mental health, primary care and adult social care, but in the new structure they work in Integrated Assessment and Inspection Teams across a regional area. Work is also ongoing to review the 'inspector' / 'assessor' split internally, with an update on this work expected in due course.
●Department of Health and Social Care says in progress · 11 Feb 2015
In January 2014, the Care Quality Commission started its new inspection programme for mental health trusts, community trusts and general practice out of hours services. In April 2014, the first new style inspections started in adult social care. The Care Quality Commission’s rating of providers will commence in Independent Mental Health (community and hospitals), NHS Specialist Acute Hospitals and NHS Ambulance Trusts is expected to start in early 2015.
What other bodies have found
●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 3 new roles – Chief Inspector of Hospitals, Chief Inspector of Primary Care and Chief Inspector of Adult Social Care —tasked to ensure that inspections were no longer a tick box exercise. The Care Quality Commission was said to have developed a new inspection framework which set out five domains against which to assess providers. New inspection regime. Inspection teams were to be made up of senior and junior doctors, nurses, allied health professionals, senior managers and people with experience of using hospital services.
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.