Chapter 42. Care Quality Commission

Background

In Chapter 7, I dealt with the CQC inspection of the Countess and set out in brief outline its role in regulating healthcare. I repeat some of the background here for ease of reference.
CQC is the independent regulator of healthcare in England. It was established on 1 April 2009 by the Health and Social Care Act 2008. It is an executive non-departmental public body sponsored by DHSC and is accountable to Parliament through the Secretary of State for Health and Social Care.¹ It replaced, and brought together, the Healthcare Commission, the Mental Health Act Commission and the Commission for Social Care Inspection. CQC was to streamline oversight of the health and social care sector.² CQC is responsible for the registration, monitoring, inspection and regulation of service providers with prescribed regulated activities. This includes NHS Trusts.³ Its purpose is to ensure that health and care services provided are safe, effective, compassionate and of a high quality.⁴ The remit is enormous.
The funding for CQC in 2023/24 was £294.4 million, made up of fee income from registered providers, grants from DHSC, income from contracts and other sources, and a non-cash allocation from DHSC.⁵

Changes in CQC’s approach to inspection

CQC has a duty to conduct inspections of health and social care service providers and publish a report of its findings. Initially, it took a generalist approach to inspection. In 2013, it changed its approach to inspecting and rating NHS hospitals. The change was triggered by several high-profile failures of care that raised questions about regulators’ ability to identity and act on poor performance.⁶
An example of CQC’s regulatory activities, for better or worse, is its involvement in the investigation of maternity care at the University Hospitals of Morecambe Bay NHS Foundation Trust. This preceded the 2013 changes to CQC and is an example of a high-profile failure of care in which CQC failed initially to act. In 2009, following concerns about serious incidents in maternity services, including maternal and neonatal deaths, the North West CQC team referred Morecambe Bay to the central CQC team for a potential investigation of maternity services. The central CQC investigation team declined, on the grounds that the incidents were deemed unconnected, and it was thought that there were not systemic problems. Notably, CQC was not given a key review.⁷
In 2010, CQC allowed Morecambe Bay to register with it, and Monitor granted it Foundation Trust status. In 2011, external concern about the incidents heightened.⁸ CQC, and others, went on to review Morecambe Bay maternity services. CQC uncovered poor clinical practices, inadequate staffing and weak leadership, leading to significant scrutiny of the hospital’s management.⁹ In 2015, Dr Bill Kirkup published The Report of the Morecambe Bay Investigation. He found there was “significant organisational failure on the part of the CQC, which left it unable to respond effectively to evidence of problems”.¹⁰
Post-2013, CQC changed its approach so as to include larger and more specialist teams of inspectors and experts with experience of hospital care.¹¹ As set out in Chapter 7, the inspection teams now assessed against five quality domains and produced ratings in an inspection report. The five domains concerned whether the service provider was safe, effective, caring, responsive and well-led.¹²
The fact that CQC had not been provided with an important document when being asked to investigate Morecambe Bay, coupled with the swingeing findings of Dr Kirkup in his report, published in 2015, ought to have alerted CQC to the urgent need to ask more questions, to probe the answers given, or, to use the current favoured phrase, ‘show more curiosity’ during its inspections. Had it done so at the Countess in 2016, it may well be that it would have uncovered the rise in the mortality rate. As I said in Chapter 7, Children’s and Young People’s services were rated ‘good’ overall and ‘good’ in the categories ‘effective’, ‘caring’, ‘responsive’ and ‘well led’.  The rating for the ‘safe’ category was ‘requires improvement’ because of shortages of nursing staff.

Strategies

In 2016, CQC released its five-year Shaping the Future strategy.¹³ CQC aimed to build a unique baseline of knowledge by inspecting all service providers. This would then enable CQC to target inspections where poor care, or change in quality, was more likely.¹⁴
In September 2018, Alliance Manchester Business School and the King’s Fund published a report on the impact of CQC on the performance of the hospitals and other settings they inspected.¹⁵ The report found that, overall, providers accepted and generally supported the need for quality regulation within the health and care system, and saw the approach introduced by CQC in 2013 as a significant improvement on the system it replaced.¹⁶
The following year, in 2019, Alliance Manchester Business School was commissioned to do a further report. This was published in 2020 and focused on CQC’s impact on the quality of care. In short, performance was patchy.¹⁷
In 2021, CQC released A New Strategy for the Changing World of Health and Social Care.¹⁸ Alongside the new strategy, CQC introduced an organisational restructure, a single assessment framework across all the sectors that CQC regulated, and a new IT system, named the regulatory platform (with a provider portal).¹⁹

Dr Dash’s review

Only three years after the publication of the new strategy, Dr Penny Dash published her report into the operational effectiveness of CQC, in October 2024.²⁰ Dr Dash found:
“significant failings in the internal workings of CQC, which have led to a substantial loss of credibility within the health and social care sectors, a deterioration in the ability of CQC to identify poor performance and support a drive to improve quality – and a direct impact on the capacity and capability of both the social care and the healthcare sectors to deliver much-needed improvements in care”.

Dr Dash came to ten conclusions and made seven key recommendations.²¹ These repay re-reading.

CQC’s IT system failures

To register with CQC, providers are required to meet the fundamental standards set out in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Regulation 13 requires providers to safeguard service users from abuse and improper treatment.²²
CQC’s guidance for providers specifies: “[W]here a provider becomes aware of any allegation or evidence of abuse, they must take appropriate action without delay, which must include investigation and may also include referral to an appropriate body.”²³ It is not the role of CQC to investigate safeguarding concerns. If CQC is the first recipient of a safeguarding concern, it should make a referral to the local authority, which has a responsibility to investigate under the Care Act 2014.²⁴
In 2016, in the context of neonatal services, CQC assessed safeguarding issues, as required by Regulation 13, by looking at data from NHS England on StEIS and the NRLS. This information was included in a data pack that was shared with the inspection team, for them to consider whether there were any issues with patient safety.²⁵ The inspectors were expected to speak to, and observe, staff delivering care, and to speak to patients who had received care.²⁶ I have described the flaws in the process before and during the Countess inspection in February 2016 in Chapter 7.
Post-2021, CQC introduced a new regulatory platform and provider portal. The Dash Review of CQC found that the development of these IT systems caused practical issues and time loss for CQC staff and service providers. Uploading evidence to the portal caused delays in the inspection process and the production of reports. CQC’s referrals to local authorities contained inadequate information and CQC had challenges in ensuring concerns raised were being managed in a timely manner. The Dash Review of CQC in 2024 demonstrated that IT system failures were hindering CQC’s safeguarding role.²⁷ The first recommendation of the Dash Review of CQC involved CQC fixing the provider portal and regulatory platform.²⁸

Professor Sir Mike Richards’ review

Professor Sir Mike Richards was also commissioned by CQC to consider the impact of the changes that it had made following its 2021 strategy. His report was also published in October 2024. It found that the changes had “major adverse consequences” and failed to deliver the benefits that were intended.²⁹
The review found that fewer inspections were carried out than in previous years. There were serious concerns about the inspection process and quality of reports. The single assessment framework was far too complex. One size did not fit all. It did not allow for the huge differences in the size and functional range of the services that CQC regulates. The regulatory platform was found to have a serious adverse impact on the working lives of CQC staff and provider organisations, who were expected to upload information onto the provider portal. Staff morale was found to be low. A finding was made that CQC was now unable to fulfil its purpose to ensure that providers’ services were safe, effective, compassionate and high quality.³⁰

Current position

In October 2024, CQC made a public statement in which it “accepted the high-level recommendations of both reports [by Dr Dash and Sir Mike], which identify serious organisational failings, and is taking rapid action in response”.³¹
The same month, CQC announced the appointment of a new Chief Executive, Sir Julian Hartley. Sir Julian has experience of leadership roles in numerous hospitals. He was the Chief Executive of Leeds Teaching Hospitals NHS Trust for a decade.³² In October 2025, an inquiry into poor maternity care and avoidable deaths in maternity services at Leeds Teaching Hospitals NHS Trust was announced. The Inquiry’s work will include examining the time period during Sir Julian’s tenure as Chief Executive. Sir Julian resigned from CQC, explaining: “[M]y current role as Chief Executive of CQC has become incompatible with the important conversations happening about care at Leeds Teaching Hospitals NHS Trust, including during the time I was Chief Executive there.”³³ Dr Arun Chopra became the interim Chief Executive of CQC at the end of October 2025.³⁴
Sir Mike became Chair of CQC in April 2025.³⁵ On 6 February 2026, he stepped down as Chair on the grounds that the turnaround of CQC needed a longer-term commitment than he was able to make. He also considered that a new Chair should lead the search for a permanent Chief Executive.³⁶ He agreed to remain in post until the appointment of his successor, but due to personal circumstances, as of 1 June 2026 a new caretaker Chair has been appointed, Ms Kay Boycott, until a substantive appointment to the role can be made.
CQC has not often achieved its purpose since it was set up in 2009. There have been two strategies to which I have referred. The strategies have failed. I am confident that informed and very able people are now looking at the way ahead, and it is not for me to opine on how to improve it. I would suggest, however, that after 17 years and a number of failed strategies, it needs more than a reboot. It needs to focus on its core purpose and develop teams who work to achieve that purpose. It is essential that the new Chief Executive is an exceptional leader and manager, who is supported by an outstanding team. CQC must not fail again. For that reason, I would counsel extreme caution before adding to its responsibilities until it has achieved the transformation required.
I recognise and welcome that, as I write in June 2026, and in marked contrast to its predecessors, the most recent iterations of the CQC website, from November 2025 onwards, have a clear focus on patients and those in care homes and the importance of listening to what they have to say.³⁷ I hope this marks the beginning of real improvement at CQC.