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 say in progress (Feb 2026)Department of Health and Social Care says in progress (Feb 2015)
Recommendation, verbatim from the inquiry
●Inquiry recommendation
Patients, through their user group representatives, should be integrated into the structure of the Care Quality Commission. It should consider whether there is a place for a patients' consultative council with which issues could be discussed to obtain a patient perspective directly.
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, in commentary published in February 2026, the Department of Health and Social Care and NHS England reported that the Care Quality Commission still retains its Experts by Experience programme (DHSC and NHS England, Feb 2026). Reviewing progress in May 2024, the Thirlwall Inquiry legal team noted that while user representatives had been involved through inspections and board membership, "it is unclear whether a patient’s consultative council or panel was ever constituted" (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 Care Quality Commission uses a wide range of means to engage people who use services in its work. It is holding a number of events and activities to ask people how they it can best involve patients, relatives and carers in its work. This includes looking specifically at a ‘People’s Panel’
Healthwatch England is the independent consumer champion for health and social care in England, and works closely with the Care Quality Commission. The Chair of Healthwatch England sits on the Care Quality Commission’s Board and is able to ensure a focus in the board’s considerations on the views of people who use health and care services.
The Care Quality Commission engages directly with people who use health and social care services to consult on its strategy and policy activity, as well as involving people who use services in the development of its regulatory methodologies. It also recruits, trains and supports people who use services to accompany its inspection staff on inspections (these people are known as ‘Experts by Experience’); the benefits of involving learning disabled Experts by Experience in the post-Winterbourne View hospital inspections of learning disability in-patient units were very clear. The Care Quality Commission works at a local level with overview and scrutiny committees, and Foundation Trust councils of governors, who scrutinise the different elements of the local system, to share information about the safety and quality of local services. The Care Quality Commission works with local Healthwatch and other local voluntary and community organisations, to share surveillance and intelligence to support the Commission’s regulatory function.
Delivery
●DHSC and NHS England say in progress · 27 Feb 2026
The Thirlwall Inquiry has noted action taken in response to this recommendation. CQC still retain the Experts by Experience programme.
●Department of Health and Social Care says in progress · 11 Feb 2015
The Care Quality Commission recruits, trains and supports people who use services- known as ‘Experts by Experience’- to accompany its inspection staff on inspections of health and social care services and its visits to monitor the use of the Mental Health Act. Experts by Experience also attend listening events, consultations and staff training events and take part in activities to develop the Care Quality Commission’s strategy and processes. The Care Quality Commission currently works with around 500 Experts by Experience covering a wide variety of backgrounds. During inspections, Experts by Experience spend time talking to people who use the service and observing the environment. They have first-hand experience of receiving care so they know which questions to ask to get as much information from the visit as possible. Their findings are used to support the inspector’s judgment on the service and can also be included in the inspection report.
The Care Quality Commission has received a huge amount of applications to be an Expert by Experience and have currently paused recruitment. However, the Care Quality Commission has developed an online community that people can be a part of, called the Care Quality Commission Action Team. People who are members of the Care Quality Commission’s Action Team help the Care Quality Commission to develop our policies, processes and inspection materials. The Care Quality Commission Action Team members also receive a monthly news update which lets them know how to get involved in the Care Quality Commission activities and the promotion of listening events.
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 the Chair of Healthwatch England sitting on the Care Quality Commission’s Board.
In the February 2015 Culture Change report, the Government said that the Care Quality Commission recruited and trained people who use services, known as ‘Experts by Experience’, to accompany inspection staff on inspections, as well as attend listening events, consultations, staff training events and take part in activities to develop the Care Quality Commission’s strategy and processes.
It is unclear whether a patient’s consultative council or panel was ever constituted.
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.