Home / Inquiries / Mid Staffs Inquiry / F56
← F55 F57 →
F56

Care Quality Commission independence strategy and culture

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 state no delivery position (Feb 2026)Department of Health and Social Care says in progress (Feb 2015)

Recommendation, verbatim from the inquiry

●Inquiry recommendation

The leadership of the Care Quality Commission should communicate clearly and persuasively its strategic direction to the public and to its staff, with a degree of clarity that may have been missing to date.

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In September 2024 commentary published in February 2026, DHSC and NHS England recorded this recommendation as superseded, referring to their response to recommendation 55 in relation to the Dash review (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team noted that the government had accepted the recommendation and found that the Care Quality Commission "appears to continue to publish 3-year strategies" following earlier consultations on its regulatory framework (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.
In April 2013 the Care Quality Commission published its new three year strategy, Raising Standards, putting people first – our strategy 2013–16.54 This document sets out how the Care Quality Commission will make major changes to what it does and how it does it. This was reinforced in June 2013, when the Care Quality Commission issued A new start – Consultation on changes to the way Care Quality Commission regulates, inspects and monitors care to start the public discussion on what the fundamental standards of care should be and how surveillance, inspection and monitoring might work. On 17 October 2013, it published the responses to the consultation in A new start: Responses to our consultation on changes to the way Care Quality Commission regulates, inspects and monitors care services, which showed that there is broad agreement with the new approach.
Chief Inspectors of Hospitals, General Practice and Adult Social Care have been appointed and will start a similar process of consultation and engagement on new regulatory approaches for their sectors. The Deputy Chief Inspector of Mental Health will report to the Chief Inspector of Hospitals on how they apply to mental health services.

Response document: 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 state no delivery position · 27 Feb 2026

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 “Superseded”. Table row: section 18.2 No. 56, PDF page 454.

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

Between 9 April and 4 June 2014 the Care Quality Commission consulted on how it planned to change the way it regulates, inspects and rate care services. The changes include things like:

• what the Care Quality Commission look at on an inspection.
• how the Care Quality Commission judge what 'good' care looks like.
• how the Care Quality Commission rate care services to help people judge and choose care if they want to.
• how the Care Quality Commission use information to help decide when and where to inspect.

The Care Quality Commission has published consultation handbooks for seven services and consulted on enforcing the fundamental standards. More information is provided in response to recommendation 14.

In July 2014, the Care Quality Commission published a consultation on guidance for providers meeting the fundamental standards and on the Care Quality Commission’s enforcement powers.

The consultation closed on 17 October 2014. The Care Quality Commission is considering the responses and will publish its new guidance ahead of the regulations coming into force in April 2015

As part of its 2014-15 business plan the Care Quality Commission has published details of how it will measure its impact, outcomes, quality, effectiveness and internal capabilities. See response to recommendation 55.

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.

The Government referred to various consultations which the Care Quality Commission undertook, including in autumn 2013 as to how fundamental standards of care, surveillance, inspection and monitoring should work; in spring 2014 on how it planned to change the way it regulated, inspected and rated care services; and in summer 2014 on its guidance for meeting the fundamental standards.

The Care Quality Commission appears to continue to publish 3-year strategies.

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. 56, PDF page 418.

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.