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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 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 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.

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 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.

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 “Implemented – Ongoing”. Table row: section 18.2 No. 58, PDF page 454-455.

●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.

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 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.

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. 58, PDF page 419.

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.