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CQC

The Care Quality Commission (CQC) is the independent regulator of health and adult social care services in England, responsible for ensuring that care providers meet fundamental standards of safety and quality.^[1] Established in April 2009 under the Health and Social Care Act 2008, the CQC replaced three predecessor organizations—the Commission for Social Care Inspection, the Healthcare Commission, and the Mental Health Act Commission—to create a unified regulatory body for the sector.^[2]^[3] The CQC's primary functions include registering care providers, conducting inspections, publishing reports, and assessing compliance with legal standards, covering a wide range of services from hospitals and GP practices to care homes and domiciliary care. It evaluates services against five key questions—is the service safe, effective, caring, responsive, and well-led?—assigning ratings of outstanding, good, requires improvement, or inadequate to guide public choice and drive improvements. As of 2025, the CQC regulates over 28,000 services and has expanded its assessments to include all 153 local authorities in England for their adult social care duties under the Care Act 2014.^[1]^[4] In recent years, the CQC has focused on enhancing its regulatory approach through initiatives like "Better regulation, better care," which emphasizes proportionate oversight, data-driven assessments, and collaboration with providers to address systemic challenges such as workforce shortages and post-pandemic recovery.^[5] Its annual State of Care report, including the 2024/25 edition, highlights trends in care quality, identifies risks like uneven service improvements, and recommends actions to safeguard vulnerable populations.^[6] Leadership transitions, including the appointment of Dr. Arun Chopra as Interim Chief Executive in 2025 following Sir Julian Hartley's resignation, underscore ongoing efforts to strengthen organizational effectiveness amid evolving healthcare demands.^[7]

History and Establishment

Formation and Legal Basis

The Care Quality Commission (CQC) was established on 1 April 2009 as an executive non-departmental public body sponsored by the Department of Health, operating independently to regulate health and adult social care services in England.^[8] Its creation marked a significant consolidation in the regulatory landscape, aiming to streamline oversight across sectors previously handled by multiple entities.^[4] The legal foundation of the CQC is provided by the Health and Social Care Act 2008, which established the Commission under Section 1 and outlined its core functions in Part 1.^[9] The Act's primary mandate for the CQC is to protect and promote the health, safety, and welfare of people using health and social care services while improving the quality of those services.^[9] This framework emphasizes outcome-focused regulation to ensure services meet essential standards without imposing undue administrative requirements.^[10] The CQC was formed through the merger of three predecessor organizations: the Commission for Social Care Inspection (CSCI), the Healthcare Commission, and the Mental Health Act Commission, as detailed in Section 6 and Schedule 2 of the 2008 Act. This integration transferred their regulatory powers, inspections, and monitoring duties to the CQC, eliminating overlaps in responsibilities for social care, healthcare, and mental health oversight. The initial objectives included reducing the regulatory burden on providers by creating a unified system and enhancing accountability across England's health and social care sectors, as the fragmented prior structure had led to inefficiencies and duplicated efforts.^[11]

Early Developments and Mergers

Following its establishment in April 2009, the Care Quality Commission (CQC) faced significant challenges in merging the staff and systems of its three predecessor bodies: the Commission for Social Care Inspection (CSCI), the Healthcare Commission, and the Mental Health Act Commission (MHAC). These organizations had distinct cultures, methodologies, and operational approaches, leading to integration difficulties that were exacerbated by austerity measures and a 6% reduction in the recurring budget from £175 million in 2008-09 to £164 million in 2010-11. As a result, the CQC experienced initial operational delays, including high staff vacancy rates of 14% by September 2011, particularly among registration assessors and compliance inspectors, which hampered the timely rollout of regulatory activities.^[12] The CQC launched its first inspections in 2010, focusing on compliance with the 16 essential standards of quality and safety outlined in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. These standards covered key areas such as dignity and respect, consent to care and treatment, and safeguarding service users from abuse, aiming to ensure baseline protections across health and social care providers. However, resource constraints limited the scope, with only 47% of planned compliance reviews completed between October 2010 and March 2011, prioritizing registration over ongoing monitoring.^[13]^[14] The CQC's scope expanded under the Health and Social Care Act 2012, which transferred responsibility for registering and monitoring primary medical services—such as general practices—from the former General Medical Council oversight to the CQC, effective from October 2013. This broadened the regulator's remit to include over 8,000 primary care providers, necessitating further staff recruitment and system adaptations amid ongoing integration issues. A key early report, the National Audit Office's 2011 review of the CQC's regulatory effectiveness, underscored teething problems like inconsistent inspection practices due to inadequate performance management and varying assessor expertise, recommending improved training and data systems to enhance consistency.^[15]^[12]

Organisational Structure

Governance and Board

The Care Quality Commission's governance is led by its Board, the senior decision-making body responsible for providing strategic direction and oversight of the organisation's operations. As of November 2025, the Board comprises approximately 12 members, including the Chair, executive directors such as the Chief Executive and Chief Inspectors, and non-executive directors who bring independent perspectives on policy, risk, and performance. The current Chair is Professor Sir Mike Richards, appointed in March 2025, who leads the Board in ensuring alignment with the CQC's regulatory objectives.^[16]^[17] The Board's primary roles include strategic oversight of the CQC's activities, approval of key policies and the annual business plan, and ensuring accountability for the effective regulation of health and social care services in England. It holds ultimate responsibility for the organisation's performance, risk management, and compliance with statutory duties under the Health and Social Care Act 2008. The Board meets six times per year to review progress against strategic goals and address emerging challenges, such as those outlined in the 2025/26 business plan, which includes a review of governance arrangements to enhance efficiency and responsiveness.^[18]^[19]^[20] Board members are appointed by the Secretary of State for Health and Social Care, following a public appointments process governed by the Governance Code for Public Appointments to ensure transparency, merit, and diversity. Non-executive directors, including recent appointees such as Kay Boycott, Alex Kafetz, Michael Mire, Ruth Owen, Melanie Williams, and Richard Barker in June 2025, typically serve terms of three to five years, renewable subject to performance review. This structure supports independent scrutiny while maintaining alignment with government priorities.^[21]^[22] To support its functions, the Board is assisted by key committees, notably the Audit and Risk Assurance Committee, which provides assurance on financial reporting, internal controls, and risk management. Chaired by non-executive director Kay Boycott as of June 2025, the committee includes independent members and focuses on compliance governance, reviewing audit outcomes and advising the Board on mitigating organisational risks. The CQC remains accountable to Parliament through the Department of Health and Social Care, with the Board ensuring delivery against this framework via regular reporting and scrutiny.^[16]^[23]^[20]

Leadership and Operational Teams

The Chief Executive of the Care Quality Commission (CQC) is responsible for the day-to-day management of the organization, including the delivery of its business plan, strategic implementation, and oversight of resource allocation across regulatory activities. As of November 2025, Dr. Arun Chopra serves as Interim Chief Executive, having assumed the role following the departure of Sir Julian Hartley in October 2025; Chopra previously joined the CQC as Chief Inspector of Mental Health in March 2025. The Chief Executive reports to the Board and works closely with executive directors to ensure alignment between strategic goals and operational delivery. The CQC's leadership includes specialized Chief Inspectors who head domain-specific teams, focusing on inspection, assessment, and improvement in key sectors. Chris Badger was appointed Chief Inspector of Adult Social Care and Integrated Care in June 2025, leading teams that oversee residential, community, and integrated care services with an emphasis on person-centered outcomes. Dr. Toli Onon joined as Chief Inspector of Hospitals in September 2025, directing hospital inspection teams to evaluate acute and specialist care standards, drawing on her background as a consultant obstetrician. Professor Bola Owolabi became Chief Inspector of Primary Care and Community Services in July 2025, guiding assessments of GP practices, community health services, and related providers to promote equitable access and quality. Chris Dzikiti currently acts as Interim Chief Inspector of Mental Health, managing teams focused on inpatient and community mental health services following Chopra's transition to the executive role. Operational teams at the CQC comprise approximately 3,200 whole-time equivalent staff as of 2024, including around 3,176 directly employed personnel such as inspectors, analysts, and regional managers who conduct assessments and support enforcement. These teams are organized across England, with offices in key locations including London, Newcastle, Leeds, Nottingham, and Birmingham to facilitate nationwide coverage, though the exact number of operational regions aligns with national service distribution rather than a fixed count of ten. Staff are grouped into directorates like Operations, Regulatory Leadership, and Engagement to handle inspections, data analysis, and stakeholder collaboration. Recruitment for inspectors prioritizes multidisciplinary expertise, seeking professionals such as clinicians, social workers, and safeguarding specialists to ensure comprehensive evaluations. Training programs include mandatory bespoke safeguarding modules at Levels 1-3, with Level 3 required for those involved in assessments or concern handling, supplemented by involvement of Experts by Experience in over 2,730 instances and specialist advisors in more than 2,800 inspections during 2023/24. The CQC emphasizes diverse recruitment to enhance representation, though challenges persist in filling roles in legal, technology, and data specialties.

Regulatory Framework

Scope of Regulation

The Care Quality Commission (CQC) regulates health and adult social care services exclusively in England, encompassing over 28,000 services and locations across the sector.^[4] This jurisdiction does not extend to Scotland, Wales, or Northern Ireland, where separate regulatory bodies handle oversight due to devolved powers.^[24] Registration with the CQC is mandatory for providers carrying out any of the 14 regulated activities defined under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, such as personal care, nursing care, or treatment of disease, transport, or injury.^[25] The regulated services span a wide range of public and private entities, including NHS hospitals, independent hospitals and private clinics, general practitioner (GP) practices and primary medical services, care homes providing residential or nursing care for adults, home care agencies delivering personal or nursing support, dental practices, independent ambulance services, and mental health inpatient and community services.^[26] For example, this includes over 10,000 dental services and thousands of care homes and homecare providers, ensuring consistent standards in treatment, care, and support delivery.^[26] Providers must register each location where regulated activities occur, even if services are delivered irregularly or at multiple sites.^[24] Additionally, since December 2023, the CQC has been assessing the performance of all 153 local authorities in delivering adult social care duties under the Care Act 2014.^[27] Certain services fall outside the CQC's scope, such as purely private medical practices that do not perform regulated activities and therefore require no registration, as well as non-clinical support services like administrative or logistical functions without direct involvement in health or social care provision. The scope of regulation has expanded since the CQC's establishment; primary medical and dental services were brought under its oversight in 2013 and 2011 respectively, while independent ambulance services entered the regulatory framework in April 2011, marking the first formal regulation of these providers.^[28]^[29]^[30]

Powers and Enforcement Mechanisms

The Care Quality Commission (CQC) derives its statutory powers primarily from the Health and Social Care Act 2008, which mandates the registration of providers carrying out regulated activities in health and adult social care in England.^[31] Under sections 10 to 17 of the Act, providers must apply for registration before commencing regulated activities, with the CQC assessing applications and granting registration subject to conditions if fundamental standards are met; failure to register constitutes an offence punishable by a fine or up to 12 months' imprisonment.^[31] The CQC also monitors compliance through ongoing inspections and information gathering, as outlined in section 20, which requires providers to meet regulations set by the Secretary of State on matters such as safe care, safeguarding, and nutrition. De-registration, or cancellation of registration, can occur under section 17 if a provider commits offences, fails to comply with conditions, or poses risks to service users, allowing the CQC to remove non-compliant entities from operation. For enforcement, the CQC employs a range of graduated options under the 2008 Act to address non-compliance. Warning notices, per section 29, are issued when a provider breaches regulations or conditions, specifying the issue and requiring remedial action within a set timeframe, with non-compliance potentially leading to further measures.^[32] Fixed penalty notices offer an alternative for certain offences, imposing fines of £4,000 on providers or £2,000 on managers for breaches like failing to meet safe care standards under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, discharging liability if paid promptly but escalating to prosecution if refused.^[33] Urgent suspension of services is available under sections 30 and 31 for immediate risks to health or welfare, allowing temporary halts to regulated activities via notice or court order, extendable as needed. Prosecutions occur in magistrates' courts for serious or persistent breaches, such as those under Regulations 12 (safe care) or 13 (safeguarding), with penalties including unlimited fines or imprisonment (up to 2 years for certain offences), particularly where avoidable harm or risk arises.^[34] The CQC utilizes improvement notices and compliance actions as proactive tools, requiring providers to submit plans addressing specific deficiencies without immediate harm, with failure to comply treated as an offence under the 2008 Act.^[35] Escalation follows a structured process: initial actions like warning or improvement notices may progress to civil sanctions (e.g., registration conditions or fines) or criminal proceedings for grave violations, guided by the CQC's four-stage decision-making framework to ensure proportionality.^[36] In exercising these powers, the CQC collaborates with bodies such as the Health and Safety Executive (HSE) to align enforcement on overlapping issues like workplace safety, sharing information and coordinating actions to avoid duplication and enhance effectiveness.^[35] This joint approach extends to notifications under section 39 of the 2008 Act, where the CQC informs entities like local authorities or NHS bodies of enforcement decisions affecting services.^[37]

Inspection and Monitoring Processes

Rating System and Methodology

The Care Quality Commission's (CQC) assessment framework, under the Single Assessment Framework (SAF) introduced in 2023 and rolled out to acute hospitals from that year with full expansion by 2025, is built around five fundamental key questions that evaluate the quality of health and social care services: Is the service safe? Is it effective? Is it caring? Is it responsive to people's needs? Is it well-led? These questions, introduced in October 2014 as part of a new inspection regime, replaced earlier compliance-focused approaches with a more holistic evaluation of care quality, aligning with the Health and Social Care Act 2008 regulations.^[38]^[39] Ratings are assigned on a four-point scale—outstanding, good, requires improvement, or inadequate—reflecting the service's performance against each key question and quality statements derived from them. These ratings apply at multiple levels: overall for the provider or location, for each of the five domains (key questions), and for specific services within a provider, enabling granular and comparative insights into care standards. Scores are derived from evidence gathered during assessments, with thresholds such as 88% or higher for outstanding and 63-87% for good, calculated via professional judgment on statements scored from 1 (inadequate) to 4 (outstanding).^[40]^[41] The CQC employs three main inspection methodologies to gather evidence: comprehensive inspections, which provide a full evaluation against all five key questions and are typically unannounced for acute hospital services to capture routine practices; focused inspections, which target specific concerns or changes such as follow-ups on previous ratings; and responsive inspections, initiated rapidly in response to serious risks or complaints. Evidence is triangulated from diverse sources, including direct observations and interviews during on-site visits, national patient and staff surveys (e.g., the NHS patient survey programme), analysis of complaints and incidents, statutory notifications from providers, and ongoing digital monitoring of performance data.^[42]^[41] To inform national oversight, the CQC produces an annual State of Care report, which aggregates inspection outcomes, survey results, and trend data to highlight systemic patterns in care quality across England, such as improvements in specific domains or persistent challenges.^[43]

Hospital and Acute Care Inspections

The Care Quality Commission (CQC) conducts inspections of NHS and independent acute hospitals as part of its broader regulatory role, focusing on ensuring safe, effective, and responsive care delivery. Comprehensive inspections for acute trusts rated Good are scheduled every 2 years, for Outstanding every 2.5 years, while those rated Requires Improvement undergo re-inspection within 12 months, and Inadequate ratings prompt immediate action plans with follow-up visits typically within six months.^[44]^[45] These inspections incorporate ongoing monitoring through data sources like national audits and patient feedback, with focused visits addressing specific risks; in recent years, the CQC has completed assessments of dozens of acute trusts annually.^[46] Inspections utilize the Key Lines of Enquiry (KLOEs), structured around five domains—is the service safe, effective, caring, responsive to people's needs, and well-led?—to evaluate core hospital services such as urgent and emergency care, maternity, and critical care. Particular emphasis is placed on high-risk areas like emergency departments, where inspectors assess triage processes and patient flow; maternity services, including labour ward safety and postnatal support; and infection prevention and control, reviewing protocols for hygiene, antimicrobial stewardship, and outbreak management.^[47]^[48] Evidence is gathered through on-site observations, staff interviews, patient records, and multidisciplinary reviews, with findings triangulated against the general rating methodology of scoring domains from 1 to 5 and aggregating to overall judgements.^[40] As of the 2024/25 State of Care report, a majority of NHS acute hospital core services were rated Good or Outstanding overall, reflecting improvements in areas like surgical outcomes and patient experience, though domain-specific ratings vary.^[49] However, persistent challenges include staffing shortages, with reports highlighting understaffing and skill mix issues affecting care delivery across emergency and maternity units, contributing to burnout and delayed responses.^[50] A&E performance remains a concern, with over 1.8 million patients waiting more than 12 hours from decision to admit to admission in emergency departments during 2024/25, a 10% increase from the previous year, often linked to bed occupancy pressures and discharge delays.^[50] Post-COVID-19, the CQC has integrated technology into its processes, incorporating virtual inspections via video calls, document reviews, and remote data sharing to maintain oversight during disruptions or for follow-ups, reducing reliance on physical visits while ensuring comprehensive evidence collection.^[51] This hybrid approach, introduced in 2020 and refined by 2022, allows for targeted assessments of infection control compliance and service recovery without compromising inspection rigour.^[48]

Sector-Specific Oversight

The Care Quality Commission (CQC) regulates adult social care services in England, including care homes and approximately 13,000 domiciliary care providers, to ensure the safety, effectiveness, and quality of care provided to vulnerable adults.^[52] These regulations emphasize fundamental standards that protect dignity, promote person-centered care, and prevent abuse, with providers required to maintain safe environments, respond to risks, and safeguard individuals from harm through robust policies and staff training.^[53] The oversight covers residential care homes for older people and those with disabilities, as well as home-based services like personal care and supported living, aiming to support independence while addressing vulnerabilities such as isolation or dependency.^[54] Under the Single Assessment Framework, the CQC conducts ongoing assessments of social care providers based on risk, data, and intelligence, with on-site inspections occurring more frequently for lower-rated or higher-risk services, and prompted by safeguarding alerts, complaints, or emerging issues.^[45] These inspections evaluate compliance across key areas, including the 'well-led' domain, which assesses governance, leadership, and organizational culture to ensure providers have effective systems for risk management, continuous improvement, and equitable care delivery.^[55] Under the Single Assessment Framework, 'well-led' quality statements focus on shared direction and culture, capable leadership, and workforce support, with inspectors reviewing evidence like governance records and staff feedback to determine if providers foster inclusive environments that reduce inequalities and promote learning.^[55] As of 2025, the CQC's State of Care report highlights improvements in infection prevention and control in social care settings following the COVID-19 pandemic, with examples of providers implementing enhanced monitoring protocols to resolve previous breaches and maintain safer environments.^[56] However, ongoing challenges persist, including staffing shortages with vacancy rates reaching 10% in homecare—double those in care homes—and high turnover at 25% in residential settings, which strain service delivery and contribute to delays.^[56] Delayed hospital discharges linked to social care capacity account for 23% of extended stays of 14 days or more, often due to insufficient homecare availability or complex needs assessments, exacerbating bed pressures in the wider health system.^[56] A special focus within social care regulation targets services for people with learning disabilities and autism, guided by the 'Right support, right care, right culture' framework, which promotes small-scale, community-based residential options and person-centered planning to enhance independence and dignity.^[57] This includes mandatory Oliver McGowan training for all staff since July 2022, ensuring awareness of needs like communication support and crisis prevention, with the State of Care assessments revealing persistent access barriers, such as inflexible GP systems and delays in discharge planning from long-term segregation.^[58]^[59]^[56] The CQC aligns this oversight with national policies like Building the Right Support, prioritizing inspections that evaluate whether services avoid institutional settings and integrate with community resources for better outcomes.^[57]

Primary and Community Care

The Care Quality Commission (CQC) assumed regulatory oversight of primary medical care services, including general practitioner (GP) practices, in April 2013, following legislative changes that extended its remit to primary care. This includes responsibility for more than 6,700 GP practices in England, where CQC conducts registrations, monitors compliance, and performs inspections to ensure services meet fundamental standards of quality and safety.^[60] CQC also regulates over 10,000 dental service providers, encompassing both NHS and independent practices, with inspections tailored on a segment-based approach that differentiates between medical and non-medical activities to assess specific risks and performance areas effectively. Emphasis is placed on critical aspects such as equitable access to appointments, safe prescribing practices to minimize medication errors, and integration of patient perspectives through established mechanisms like the GP Patient Survey, which informs inspection outcomes and improvement plans.^[61]^[62] In 2025, primary care ratings have shown positive trends, with approximately 90% of inspected GP practices achieving a Good or Outstanding overall rating, reflecting improvements in service delivery amid growing patient demands. However, persistent challenges include limited appointment availability, with 35% of patients reporting difficulties in contacting practices by phone, and inconsistencies in digital record systems that hinder accessibility for vulnerable groups such as the elderly or those with disabilities.^[60]^[62]^[63] To address these issues, CQC collaborates with NHS England on integrated care systems, supporting the shift toward community-based services through shared data on workforce distribution and targeted interventions in underperforming areas.^[62]^[64]

Controversies and Reforms

Key Scandals and Failures

The Winterbourne View hospital abuse scandal came to light in May 2011 when a BBC Panorama undercover investigation exposed systematic physical, emotional, and psychological mistreatment of vulnerable patients with learning disabilities and autism at the Castlebeck-owned facility in Bristol.^[65] Staff were filmed slapping, restraining, and verbally abusing residents, including dragging patients to the floor and mocking their distress, affecting at least 48 individuals who were subsequently referred for support.^[65] The Care Quality Commission (CQC) had failed to act on earlier whistleblower alerts and statutory notifications of incidents, including high levels of restraint (558 documented cases from 2010 to early 2011), and overlooked the absence of a registered manager, allowing the abuses to persist undetected during prior inspections.^[65] In the immediate aftermath, the hospital was closed in June 2011, 11 staff members were prosecuted for their roles—six of whom received prison sentences for what were classified as disability hate crimes—and the scandal prompted a Department of Health review that initiated a national programme to shift care from institutional settings to community-based support by 2014.^[65] In 2011, Southern Cross Healthcare, the UK's largest private provider of residential care, collapsed under financial strain, endangering services for thousands of elderly residents across its network.^[66] The company operated 752 care homes housing approximately 31,000 older people, but its business model—reliant on sale-and-leaseback arrangements that saddled it with £250 million in annual rents, coupled with low capital investment (£500 per bed annually versus an industry average of £1,000) and rising interest on debts—proved unsustainable amid falling occupancy and economic pressures following the 2008 financial crisis.^[66] The CQC's regulatory framework at the time lacked robust financial oversight mechanisms, contributing to undetected vulnerabilities despite routine compliance checks focused primarily on care quality rather than market stability.^[66] Shares were suspended in June 2011, leading to the company's dissolution, but swift interventions by the Department of Health and landlords ensured no immediate disruption to resident care, with homes transferred to new operators such as HC-One (taking over 241 sites) and Four Seasons (140 sites); however, the event exposed broader risks in the privatized care sector, including isolated neglect cases like the five deaths at the Orchid View home shortly after its handover.^[66] The Morecambe Bay NHS Foundation Trust maternity scandal, detailed in the 2015 Kirkup Investigation report, revealed profound clinical and oversight failures at Furness General Hospital's maternity unit from 2004 to 2013, resulting in preventable harm to mothers and babies.^[67] The inquiry reviewed 233 clinical cases and identified 20 instances of significant care shortcomings, including poor risk assessment, dysfunctional team-working, and an overemphasis on normal births that delayed interventions, contributing to nine maternal deaths, 22 stillbirths, and 25 neonatal deaths—among them, one mother's death and 11 babies' deaths deemed avoidable with different care.^[67] The CQC's inspections had rated the unit as low-risk (downgrading from 'red' in 2009 to 'green' by 2010) and registered the Trust without conditions in April 2010, despite red flags like a 2008 cluster of serious untoward incidents (including two maternal and two neonatal deaths) and reliance on flawed assurances from local health authorities, missing systemic issues in governance and incident learning.^[67] Outcomes included leadership overhauls by 2012, a formal apology to affected families, and enhanced NHS-wide maternity safety measures, though police investigations into related deaths followed the report's release.^[67] The 2019 Whorlton Hall abuse case involved the exposure of institutional mistreatment at a specialist hospital in County Durham for adults with learning disabilities and autism, run by Cygnet Healthcare.^[68] A BBC Panorama investigation using hidden cameras from October 2018 to May 2019 captured staff mocking, taunting, and physically intimidating residents—such as pinching, restraining without justification, and exploiting vulnerabilities to provoke distress—in a facility housing up to 19 patients, all of whom were subjected to a toxic culture of control and dehumanization.^[68] Despite a 2015 CQC inspection uncovering safety risks (including improper seclusion practices) that warranted a 'requires improvement' rating, the report was unpublished due to evidential and quality issues, and subsequent 2016 and 2018 inspections rated the service 'good' overall, overlooking the closed staff culture and whistleblower concerns through inadequate evidence gathering and inconsistent enforcement.^[68] Following the broadcast on 22 May 2019, 16 staff were suspended, 10 arrested on suspicion of ill-treatment, the hospital was closed, and patients were relocated; the incident spurred CQC internal reviews and reinforced calls for stricter scrutiny of secure mental health units.^[68] These scandals collectively highlighted CQC oversight gaps and influenced subsequent regulatory reforms aimed at bolstering whistleblower protections and inspection rigor.^[65]

Reviews, Criticisms, and Changes

In 2013, Professor Don Berwick's independent review of patient safety in the NHS sharply criticized the Care Quality Commission's (CQC) reliance on prescriptive, tick-box inspection methods, arguing that such approaches were ineffective for fostering genuine quality improvement and often failed to address underlying cultural and systemic issues in health and social care regulation.^[69] Berwick recommended a fundamental cultural shift within the NHS and its regulators toward prevention of harm through continual learning, transparency, and a simplified regulatory framework that prioritizes safety over compliance checklists, emphasizing the need for all organizations to commit to zero harm as a guiding principle.^[69] Subsequent external scrutiny, including the House of Commons Health and Social Care Committee's 2018-19 inquiry into the CQC's State of Care report, highlighted persistent issues such as delays in completing and publishing inspection reports, which undermined timely oversight and provider accountability. The inquiry also raised concerns about potential conflicts of interest in the CQC's operations, particularly in how relationships with regulated providers might influence inspection rigor and independence, calling for stronger safeguards to maintain public trust.^[70] In response to these critiques, the CQC introduced its Transitional Regulatory Approach in September 2020, aimed at reducing bureaucratic burdens on providers by streamlining inspection processes and focusing on targeted, risk-based assessments rather than comprehensive reviews for all services.^[71] This reform incorporated elements of digital regulation, leveraging data analytics and technology to enhance monitoring efficiency and support a shift toward proactive oversight, as outlined in the CQC's broader strategy for adapting to evolving care delivery models.^[72] In October 2024, two independent reviews further scrutinized the CQC's performance. Dr. Penny Dash's review into operational effectiveness concluded that poor internal processes, including inadequate IT systems and leadership issues, had led to significant failings, loss of credibility among providers, and an inability to ensure safe care, recommending seven key changes such as improved governance and resource allocation. Complementing this, Professor Sir Mike Richards' review of the CQC's single assessment framework found implementation flaws since its 2023 rollout, including inconsistent application and insufficient provider engagement, and proposed refinements to enhance transparency and effectiveness in ratings. These reviews prompted the CQC to accept all recommendations and integrate them into its reform agenda.^[73]^[74] From 2023 to 2025, the CQC advanced its reforms by emphasizing workforce intelligence through enhanced data collection on staffing levels and skills, integrated into its intelligence-led regulatory framework to better anticipate risks in care quality.^[19] Additionally, the organization began piloting AI-assisted monitoring tools to analyze real-time data for early warnings on potential safety issues, enabling more efficient targeting of inspections without increasing overall workload.^[75] Despite these changes, ongoing criticisms in 2025 center on resource constraints that have exacerbated inspection backlogs, with reports indicating that resource limitations have led to significant delays; for instance, over 70% of homecare providers either lack a current CQC rating or have outdated assessments from more than four years prior, growing the effective backlog amid sector expansion.^[76] Further concerns emerged from a March 2025 High Court ruling in R (Cygnet Health Care Ltd) v Care Quality Commission, which found apparent bias in inspections led by a conflicted inspector, leading to a declaration of unfairness and orders for reconsideration of ratings, underscoring risks to impartiality.^[77] In November 2025, a BBC investigation revealed that a fifth of care homes rated "inadequate" had not been reinspected within a year, with 75% of "requires improvement" homes facing similar delays under the risk-based framework introduced in 2021, raising alarms about patient safety and family distress.^[78] These issues have prompted calls for increased funding and staffing to restore the CQC's capacity for comprehensive, timely regulation.^[73]

Funding and Impact

Budget and Resources

The Care Quality Commission's annual operating income for the 2020/21 financial year totaled £207 million.^[79] This funding was primarily derived from registration and regulatory fees paid by providers, accounting for approximately 88% of the total, with the remaining 12% coming from government grants provided by the Department of Health and Social Care (DHSC) to support non-chargeable activities such as monitoring the Mental Health Act.^[80] By the 2025/26 financial year, the CQC's net expenditure budget is projected to rise to £296.8 million, reflecting increased operational demands including digital transformation initiatives and expanded regulatory scope under the Health and Care Act 2022.^[19] Fee income is expected to constitute £225.9 million (76%), supplemented by £55.5 million in Grant-in-Aid from DHSC (19%) and other sources.^[19] In terms of human resources, the CQC employed an average of 3,063 full-time equivalent (FTE) staff during 2020/21, with 3,022 directly employed in operational and support roles.^[80] Staffing levels have since grown to support the rollout of digital tools, such as the Provider Portal and enhanced data analytics systems for streamlined assessments, reaching an average of 3,200 FTE in 2023/24 and budgeted at 3,478 FTE for 2025/26.^[81]^[19] A significant portion of the workforce consists of inspectors and assessors, who conduct on-site visits and evaluations across health and social care settings, while the remainder supports policy development, administrative functions, and IT infrastructure.^[82] Resource allocation prioritizes core regulatory functions, with around 60% of the budget directed toward inspections and ongoing monitoring activities in 2020/21—specifically, 27% to comprehensive and focused inspections and 35% to routine monitoring and intelligence gathering.^[80] The remaining expenditure covers other areas including enforcement (3%), independent voice (6%), and other non-chargeable activities (14%), which include policy development, guidance, research, framework updates, IT, and support services.^[80] This distribution has evolved with investments in technology to improve efficiency, such as automated reporting tools that reduce manual processing time.^[19] As of 2016/17, the average cost per hospital inspection was around £15,000, enabling the CQC to conduct thousands of assessments annually while managing fiscal constraints.^[83] This figure accounts for inspector time, travel, and analysis, with ongoing optimizations like targeted focused inspections helping to control costs amid rising demand.^[83]

Performance and Broader Influence

The Care Quality Commission's performance is evaluated through its annual State of Care reports and service ratings under the single assessment framework, which assesses providers against key questions of safety, effectiveness, caring, responsiveness, and leadership. In the 2024/25 report, 69% of rated adult social care services achieved a rating of good or outstanding, with 67% rated good and 2% outstanding, while 26% required improvement and 4% were inadequate, based on 3,062 rated services as of 1 August 2025. Similarly, 86% of general practice services were rated good or outstanding, though challenges persist in acute hospitals, where only 53% met the good threshold. These ratings, derived from evidence categories including workforce and outcomes, indicate steady progress in compliance with fundamental standards, though workforce shortages—such as a 7% vacancy rate in adult social care and 10% in homecare—continue to impact delivery.^[49]^[56] The annual State of Care report plays a pivotal role in shaping national policy by highlighting systemic pressures and recommending targeted investments, such as in community services to support the government's 10-year health plan for shifting care from hospitals to neighborhoods. For instance, the 2024/25 edition underscores the need for enhanced workforce strategies and equitable access, informing NHS England's Urgent and Emergency Care Plan 2025/26 and the Adult Social Care Workforce Strategy, including fair pay agreements to address turnover rates averaging 25% in care homes. This influence extends to maternity care reforms, where the report's findings on staffing shortfalls and risk assessments have supported the development of a National Maternity Improvement Strategy.^[49]^[56] Beyond direct regulation, the CQC's guidance documents have contributed to NHS reforms by evaluating integrated care systems (ICSs), established under the 2022 white paper "Joining up care for people, places and populations," which aimed to integrate health and social care at local levels to reduce bureaucracy and improve outcomes. The CQC's assessments of ICSs focus on tackling health inequalities and collaborative working, providing evidence-based recommendations that align with the white paper's goals of place-based integration across primary care, community health, and social services. This includes promoting equity in access and experiences, as seen in guidance on monitoring ICS performance against national standards.^[84]^[85] Internationally, the CQC's risk-based regulatory model has been recognized as a benchmark, particularly in Australia's aged care sector, where the 2017 Carnell Review of National Aged Care Quality Regulatory Processes cited the UK's approach as performing relatively well compared to other systems and informed subsequent regulatory reforms in Australia. This model, emphasizing inspections, ratings, and enforcement, has influenced similar frameworks in jurisdictions seeking to balance compliance with improvement. While direct collaborations with the World Health Organization on care quality standards are limited, the CQC's standards align with global benchmarks for person-centered care and have supported broader international discussions on regulatory convergence.^[86]^[87] Looking ahead, the CQC's business plan for 2025/26 and equality objectives for 2025-2029 prioritize preventive regulation through smarter, data-driven oversight to reduce health inequalities and enhance equity in underserved areas, including anti-racist practices and improved outcomes for minority communities. This strategy builds on current measures to listen to service users and promote timely interventions, aiming for more flexible regulation that supports workforce diversity and preventive care models.^[19]^[88]

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CQC