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The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) reviewed the care of adults with a diagnosed learning disability who attended/were admitted to hospital as an emergency between 1st July and 30th September 2024. Care was reviewed using 666 clinician questionnaires, 366 sets of case notes, 144 primary care questionnaires, 199 organisational questionnaires, 832 healthcare professional survey responses and 82 patient/carer surveys. Recommendations Accurately record a person’s identified learning disability in the electronic patient record/clinical notes and in learning disability registers/lists. This information should be accessible across healthcare settings to ensure prompt recognition and proactive care for patients with a learning disability on arrival at hospital. Assess and implement reasonable adjustments for patients with a learning disability. This should be undertaken: proactively if the reasonable adjustments have been flagged, and in place when the patient arrives in hospital; as soon as practicable after arrival/admission to hospital and be reassessed throughout the admission. Use decision support tools to aid healthcare professionals when assessing mental capacity in patients with a learning disability. Consistently and continuously involve people with a learning disability in their care during a hospital admission. This should be from the point of arrival through to discharge. Include:support from carers as appropriate; Reasonable adjustments at all stages, e.g., using communication tools to support conversations. Commission local learning disability support services to enable equitable access to care for patients with a learning disability who attend or who are admitted to hospital. Consider: using multidisciplinary community learning disability services to provide an in-reach service; upskilling all healthcare professionals to care for people with a learning disability; locally assessing how many patients are seen annually to determine the size of the service needed.

An urgent review led by Lord John Mann examining how the NHS, including employers and UK health regulators, identify, report and respond to antisemitism and other forms of racism. Lord John Mann, the government independent advisor on antisemitism, was commissioned by the Secretary of State of Health and Social Care and the Prime Minister in October 2025 to lead a review into how the NHS and its regulatory system recognises, reports, and tackles antisemitism and other forms of racism, following multiple cases of intolerable antisemitism. Lord Mann’s report sets out a comprehensive set of recommendations to: strengthen accountability improve reporting and investigation processes embed an anti-racist culture across the health system to ensure that patients and staff are better protected from discrimination and abuse.

Prioritising patient safety is a blog series from the Parliamentary and Health Service Ombudsman (PHSO). PHSO's strategy is built around three priorities: driving public service improvement, improving the user experience, and raising awareness and trust. You’ll see all three reflected in this edition which.  shares news of an exciting new partnership with two medical schools in the north-west, and what it means for the future of the clinician-patient relationship  provides an update on Andy’s case, which was first mentioned in the Winter blog, including the positive changes the Trust has made  shares a new case involving an avoidable death and the constructive way the Trust responded to the findings. 

The government has launched the refreshed Women’s Health Strategy and Sling the Mesh are deeply upset to see no mention of mesh injured women and mesh centres in the media announcements from Government nor of the need for pelvic floor physiotherapy education for girls in school – despite a pledge for better education around periods. A brief reference to the postcode lottery of mesh centres appears on page 61 as Action 63. However, the Sling the Mesh community expected that their advocacy, particularly on highlighting how women’s voices are dismissed within healthcare – to be given far greater prominence. Its absence sends a deeply troubling message: that the experiences and needs of women harmed by mesh are no longer considered a priority. YET, it was the 2020 First Do No Harm report, the formidable Baroness Julia Cumberlege and Sling the Mesh campaign which highlighted for the first time how women’s voices were not being heard – and as forerunners called for urgent action to address this. Sling the Mesh have written to Wes Streeting, MPs and journalists. Read their letter at the link below.

A coronial investigation into the death of Roman Louie Barr, aged 22 who died on 14  December 2023, was opened on 20 June 2024 and concluded on 3 March 2026. The inquest was conducted without a jury. The conclusion reached was a short factual  narrative: “The deceased died as a result of an asthma attack. Information indicating the need for an  urgent ambulance response was not obtained, and because no ambulance was available for several hours, he was taken to hospital by his family. On the balance of probabilities, earlier intervention by an emergency ambulance would have prevented his death.”  On 14 December 2023, Roman Louie Barr suffered an asthma attack. His father collected him from work and took him home, where Roman used his nebuliser without improvement. Three calls were made to the ambulance service. During these calls, Roman was assessed as Category 2, and the family were twice advised that no ambulance would be available for several hours. They were asked whether they could transport him to hospital themselves and took the decision to do so. Evidence established that at the time of the first call, Roman was critically unwell, displaying symptoms including bluish lips, but this information was not elicited during triage. Roman was of mixed ethnicity and had a darker skin tone, as his father explained to the call handler. The NHS Pathways question requiring confirmation that the patient was “a deathly colour” was not understood by his father. Clearer prompts—such as asking whether the lips were blue or grey—were not asked. A recommendation made during the subsequent review to amend this NHS Pathways wording was not accepted by those responsible for the system’s content. Ambulance availability was severely constrained due to significant delays in hospital handovers, leaving no crews free to respond. On the balance of probabilities, had clearer wording been used and the relevant information obtained, Roman would have been categorised as Category 1, for which an ambulance would be expected to arrive within approximately ten minutes even during surge conditions. While being driven to hospital, Roman suffered a cardiac arrest. His mother moved into the footwell of the passenger side and commenced CPR as they continued their journey. On arrival at the hospital, the family vehicle was involved in a collision, during which Roman’s mother sustained serious injuries. Roman could not be resuscitated and died shortly after arrival. I also heard evidence that Roman had been using his blue (salbutamol) inhaler more frequently than recommended, indicating poor asthma control, and that neither he nor his family were aware of the clinical significance of this increased use. Following his death, the GP practice conducted a review and introduced measures to better identify and monitor patients with high salbutamol use, including keeping a list of such patients, automatically booking reviews when further inhalers are requested, liaising with community pharmacists, and placing alerts on patient records to support timely assessment. Notwithstanding the Drug Safety Update issued on 25 April 2025 reminding clinicians of the risks associated with increased salbutamol use, the evidence in this case indicates that the importance of excessive reliever use may still not be fully recognised by patients or by primary care. Matters of concern Limited awareness of salbutamol overuse Evidence showed that patients and families may not appreciate the clinical significance of increased use of the blue (salbutamol) inhaler or its association with poorly controlled asthma. Identification and follow-up of reliever overuse Evidence showed that excessive or repeated requests for salbutamol inhalers may not be reliably identified within existing systems, and there may be no consistent process for follow-up when such patterns occur, meaning deteriorating asthma may go unrecognised. Ambulance handover delays affecting emergency availability Prolonged ambulance handover times at local hospitals were a significant factor in no ambulance being available at the time help was sought, reducing emergency response capacity during periods of high demand. Risks when families transport critically unwell patients The absence of an available ambulance for several hours resulted in the family transporting Roman to hospital themselves, exposing both him and his family to significant risk during a time-critical medical emergency. Clarity of NHS Pathways triage wording Evidence showed that a key NHS Pathways question used during triage was not understood by the caller and did not elicit clinically significant information. This raises a concern that, given the reliance on scripted triage systems, such scripts may not always use wording that is easily understood by lay callers in distress

The UK Covid-19 Inquiry has published its fourth report and recommendations following its investigation into ‘Vaccines and therapeutics of the United Kingdom’. It considers and makes recommendations on a range of issues relating to the development of Covid-19 vaccines and the implementation of the vaccine rollout programme in England, Wales, Scotland and Northern Ireland. Issues relating to the treatment of Covid-19 through both existing and new medications were examined in parallel.

The paper from Carl Macrae explores why safety recommendations in healthcare often fail to produce meaningful or sustained safety improvements. It identifies common problems in how recommendations are created, used, and managed, and proposes principles to improve their effectiveness. Eight problems with safety recommendations The Abundance Problem If safety recommendations are produced in large quantities and from many different sources, they can overwhelm recipients’ capacity to respond constructively and effectively. The Rigour Problem If safety recommendations are based on weak evidence and superficial, unsystematic or flawed analysis, they can misdirect improvement effort and attention to inconsequential issues. The Specificity Problem If safety recommendations make proposals that are under-specified and do not precisely articulate risks to be addressed, or are over-specified and target localised minutiae, they can cause scattered or myopic improvement efforts. The Integration Problem If safety recommendations are developed in isolation and without regard to connections with other recommendations, safety issues or ongoing work, they can deter or distract from systemic improvement activity. The Improvement Problem If safety recommendations present definitive solutions or corrective actions, they can preclude recipients from engaging in the collaborative, exploratory and locally adaptive work of learning. The Management Problem If safety recommendations are used as a tool for directing and managing action, they can degrade or marginalise local management capabilities and impede development of robust safety infrastructure. The Compliance Problem If safety recommendations issue mandatory or directive instructions, they can generate superficial compliance-oriented behaviour and box-ticking responses without addressing underlying risks. The Accountability Problem If safety recommendations are not supported by robust processes for allocating and monitoring accountabilities for improvement, they can dilute responsibility for effecting material change. Eight guiding principles Strategic Prioritisation: Recommendations are strategically selected and prioritised to target the most compelling and important risks. Careful consideration is given to any ongoing safety improvement activities, existing guidance or prior recommendations. Recommendations are prepared in a form that is actionable and accounts for recipients’ capacity and capabilities. Analytical Rigour: Recommendations are based on robust evidence and grounded in systematic investigation and analysis. Recommendations target meaningful risks and propose credible routes to safety improvement. The evidentiary basis and logic underlying specific recommendations can be clearly explained. Calibrated Specificity: Recommendations clearly articulate and describe the specific safety risks that are being targeted and which the recommendation seeks to address. The level of detail provided by recommendations is appropriate to the form and scale of action expected to be taken. Systemic Integration: Recommendations account for existing safety improvement activities and any related or planned recommendations. System-level safety priorities are considered with reference to activities of other bodies and organisations. Recommendations are aligned to, or integrated with, those from other organisations to support systemic improvement. Enabling Improvement: Recommendations encourage rigorous reflection and analysis and enable adaptive learning. Recipients are encouraged to rigorously explore, understand and address the risks targeted by recommendations. Safety innovation and collaborative learning are supported. Capability Enhancement: Recommendations build and enhance local safety management and governance processes. Recommendations are designed to support and strengthen the safety governance capabilities and capacity of recipients, developing safety competencies. Meaningful Engagement: Recommendations aim to generate genuine engagement with the challenge of addressing the safety risks being targeted. Thoughtful, reflective, rigorous and locally adaptive responses are supported and encouraged. Opportunities for narrow or superficial compliance are minimised. Active Accountability: Recommendations assign clear responsibilities for monitoring implementation and achieving safety improvement. Recommendations are monitored and managed through robust and transparent processes for tracking progress and meaningful change and safety improvement.

The Health Services Safety Investigations Body (HSSIB) has carried out seven patient safety investigations that have touched upon care for patients with cancer, to understand why issues occur and how the healthcare system can improve. Delayed or missed cancer diagnosis can have life-changing consequences for patients and their families. On World Cancer Day 2026, Scott Hislop, Deputy Director of Investigations, draws together what was found and highlights the recommendations that aim to make cancer care safer.

In 2014 an investigation was commenced into the death of Yousef Al-Kharboush (born 23 May 2014, died 1 June 2014, aged 8 days), Oscar Barker (born 27 May 2014, died 29 June 2014, aged 1 Month) and Aviva Otte (born 10 October 2013, died 2 January 2014, aged 2 months). The investigation concluded at the end of the inquest on 23 October 2023.  Aviva’s death (January 2014) was in hospital where she had received TPN provided and compounded by the NHS establishment under a section 10 exemption. That TPN had, on balance, been contaminated by Bacillus cereus (subsequently identified as type BC.38). The Trust undertook a root cause analysis together with involving the UKHSA and its own infection and microbiological teams, but no definitive source for the outbreak was found. In June 2014 Oscar Barker and Yousef Al-Kharboush received TPN, compounded by a commercial provider, which it turned out was also contaminated by Bacillus cereus (subsequently typed as Bc.44). The compounder having positive finger dab testing for the Bacillus within its laboratory/environmental testing. This outbreak also affected other babies in other Trusts. Bacillus cereus is resistant (because it is spore forming) to the spray and wipe cleaning methods used (with alcohol) and sporocides are required to decontaminate the outside of, for example, ampoules containing one of the constituents. This was the information and a conclusion that the Trust had reached in early 2014 and therefore prior to the outbreak in May/June 2014. It had not passed on those findings either within other section 10 units compounding TPN or the wider market. Subsequently, the MHRA brought in further advice for the use of sporocides in 2015. Matters of concern There is no requirement for a section 10 exempt entity to report any of its findings to the MHRA or indeed to other Trusts or the industry in general if an adverse event occurs. The current reporting structures (for a section 10 entity) involve reporting to NHSE and the CQC but the threshold or necessity for such reporting appears unclear and, in essence, up to the Trust. There may be times when section 10 entities reach conclusions which would assist the wider industry and help to assist both other Trusts and commercial organisations in assessing their own risks and improving the provision of highly specific medication to a group of vulnerable patients. The same may also be true of commercial organisations but they have the power of the MHRA controlling and effecting recalls and actions and the wider dissemination of information. Response from NHS England

This letter from Jeremy Hunt MP, Chair of the All-Party Parliamentary Group (APPG) for Patient Safety, to Dr Penny Dash, Chair of the National Quality Board (NQB), sets out the APPG's views on how the NQB can help to create a more coherent and systematic approach to managing patient safety recommendations across the NHS. It suggests what recommendations the NQB could consider as part of this, how it could approach prioritisation and how it could measure and monitor the implementation of these actions.

This report sets out the findings of new research conducted by Healthwatch England to inform the Government’s first-ever men’s health strategy for England. They commissioned a nationally representative poll of 3,575 men aged 18+ in June 2025 and also drew on local Healthwatch engagement, with men from diverse backgrounds, spanning a wide range of ages, ethnicities, occupations, and areas.  NHS Health ChecksKey findings Only 37% of eligible men (aged 40 to 74 and with no long-term conditions) said they had ever been invited to an NHS Health Check.56% of men who’d attended a check had made lifestyle changes.92% of men who’d gone for a check would take up a future invite.Key recommendations Provide stronger direction and oversight to improve the number of invites issued, uptake rates and consistency across local authority areas.Collect and publish demographic-specific uptake data, to track how many men attend and analyse which characteristics affect uptakeLaunch an awareness campaign about the Check and encourage tailored outreach to underserved men and those at higher risk of cardiovascular disease.Prostate cancer screeningKey findings 79% of all men (including 81% of Black men) said they would be likely to attend prostate screening if the NHS introduced it routinely.Only 36% of men aged 50 and over had asked their GP for a PSA testSeven per cent of those who’d asked for a PSA test had been refused (though caution is advised on this statistic given it is a low sample)Key recommendations Policymakers should consider men’s views, alongside clinical and economic evidence, when deciding on whether to introduce a national prostate cancer screening programme.Issue clear, consistent guidance for the public and GPs on whether asymptomatic men aged 50 and older can receive, or only request, a PSA test.Mental HealthKey findings 52% of men said they would visit their GP, and only one-in-five (20%) would self-refer to NHS Talking Therapies if they experienced mental health issues.Men were significantly less likely than women to turn to their friends and family for mental health support (38% vs 45%).Key recommendations Mental health support should remain varied with a ‘no wrong door’ approach to suicide prevention and improve referrals pathways from the third sector.Improve awareness of NHS talking therapies, including clearer information on how data is handled. Data should also be disaggregated between self- and GP referrals, to understand where to target changes in behaviour to improve uptakeHealth literacyKey findings One in 10 men use AI, like ChatGPT, for health information; but mostly used the NHS.Men mostly want to receive information from the NHS via email and the NHS App.Key Recommendations Create a men’s health page on the NHS website, raise awareness of spotting and avoiding online misinformation and develop health literacy from a younger age.Priorities for changeKey findings Better GP access is the top priority for change in the NHS for men; they want to see the same GP for new and ongoing physical and mental health problems and would wait longer for an appointment to do so.Key recommendations The new strategy should focus on continuity of care, where clinically appropriate

To deliver value for money over the medium to long term, a government needs to turn its objectives into outcomes in a way that delivers the best value for every pound of taxpayers’ money while managing its fiscal position. It needs to: plan and prioritise its spending (and other activities) to address those objectives. monitor and manage both costs and value delivered. evaluate the results. adjust as necessary. report to Parliament on how it has used taxpayers’ money. This report by the National Audit Office aims to provide useful insights as officials and ministers are making changes to the planning and spending framework. It will also be useful to Parliamentarians and stakeholders seeking to scrutinise government spending and delivery.

This report presents the national state of patient safety in England in 2024. Two years on from their first report, the authors provide an updated analysis of the publicly available data. The report concludes that performance in key areas such as maternity care has deteriorated, requiring urgent attention. This report was produced by Imperial College London's Institute of Global Health Innovation in partnership with the charity Patient Safety Watch. Key figures highlighted in this report include: In 2023, the number of deaths that could have been avoided if the UK matched the top 10% of Organisation for Economic Co-operation and Development (OECD) countries was 13,495. In 2023, the UK ranked 21st out of 38 OECD countries for patient safety. Cost of harm for claims resulting from incidents in 2023/24 was £5.1 billion. Maternal deaths increased from 8.8 to 13.4 per 100,000 maternities between the 2017-2019 and 2020-2022 periods – an increase of 52.3%. In 2023, the proportion of patients who said there were enough nurses on duty to care for them was 56%. As of September 2024, the proportion of people waiting more than four hours for a treatment decision in A&E was 25%. In 2023, 65% of maternity units in England were rated as “inadequate” or “requires improvement” for safety by the Care Quality Commission. In June 2024, the number of people waiting for elective care was 7.6 million. 2 in 3 staff feel unable to carry out their jobs fully due to workforce shortages. The report sets out two recommendations to support the long-term improvement of patient safety in England: Local NHS organisations must be supported to adopt evidence-based interventions to tackle the most common safety problems causing significant harm to patients. The report’s analysis of trust patient safety plans identified six common problems that many organisations are tackling, such as pressure ulcers and patient falls. Adopting proven interventions to common problems like these would finally see the NHS truly acting like a National Health Service. The authors envisage a future where the first port of call for NHS organisations is a repository of such interventions, along with the support they need to implement them, rather than developing their own solutions from scratch. National organisations must agree on a focused set of patient safety improvement priorities for the system to rally around. The report’s analysis found a crowded landscape of patient safety bodies, an opaque process for national priority setting, and evidence that the system cannot keep pace with the volume of recommendations it receives. The authors envisage a future where patients and healthcare workers are partners in the development of these priorities, and where national organisations rationalise their own activities to ensure the NHS is supported to deliver improvements against them.

Lord Carter’s review identifies unwarranted variation in the delivery of ambulance services, as well as the potential savings of £500 million that could be made in efficiencies by 2020/21. Following Lord Carter’s 2016 review into the operational productivity of acute non-specialists trusts, the ambulance sector requested a similar review into its services to help them understand what good looks like. As well as what improvements could be made to deliver good quality, better value services for their patients. Lord Carter has produced the report into ambulance productivity in England with nine recommendations to improve patient care, efficiency and support for frontline staff who have responded to a significant rise in demand for ambulance services in recent years. The report found that if more patients were treated at the scene by paramedics or were better assessed over the phone when dialling 999 — avoiding the need for an ambulance when it is safe to do so — the NHS could treat patients closer to home and reduce unnecessary pressure on emergency departments (EDs) and hospital beds. Offering safe and quicker care could save the NHS £300m a year by 2021, with a further £200m of savings through improvements in ambulance trusts infrastructure and staff productivity.

Each year over 600,000 people die in the United Kingdom and many of these deaths occur in hospital, despite the majority of people saying that they would prefer not to die there. Approximately 70% of people die from long-term health conditions that often follow a predictable course, with death anticipated well in advance of the event. The annual number of deaths in the United Kingdom is predicted to rise to 736,000 by mid-2035. Therefore, the provision of care at the end of life must meet the needs of the population. NCEPOD reviewed the quality of care provided towards the end of life for adults with a diagnosis of dementia, heart failure, lung cancer or liver disease and have made a number of recommendations. Recommendations Ensure that patients with advanced chronic disease have access to palliative care alongside disease modifying treatment (parallel planning) to improve symptom control and quality of life. Normalise conversations about palliative/end of life care, advance care plans, death and dying. As a trigger to introduce a conversation which includes the patient and their family/carers, consider: The surprise question “Would you be surprised if this patient died within the next 12 months?” This can be used across all healthcare settings; and/or recurrent hospital admission of patients with advanced chronic disease. Ensure all patients with an advanced chronic disease are allocated a named care co-ordinator. Provide specialist palliative care services in hospitals and in the community, to ensure all patients, including those with non-malignant diseases receive the palliative care they need. Train patient-facing healthcare staff in palliative and end of life care. This training should be included in: undergraduate and postgraduate education; and tegular training for patient-facing healthcare staff. Ensure that existing advance care plans are shared between all providers involved in a patient’s care. Raise public awareness to increase the number of people with a registered health and welfare lasting power of attorney (LPA) well before it is needed. .

In May 2024, Dr Penny Dash was asked by the Department of Health and Social Care (DHSC) to conduct a review into the operational effectiveness of the Care Quality Commission (CQC). An interim report of her work, providing a high-level summary of her emerging findings, was published in July 2024. This full report summarises the final findings of the review, outlining the necessary changes to start improving CQC. It makes seven recommendations and is aimed at: health and care professionals health and social care services academic and professional institutions the general public. Alongside the review’s full report, DHSC wanted to independently determine if the review’s concerns were substantiated with objective data through the consideration of a number of research questions. A second review considering the wider landscape for quality of care, with an initial focus on safety, will be published in early 2025. The conclusions of the review are summarised around 10 topics. Conclusion 1: poor operational performance There has been a stark reduction in activity with just 6,700 inspections and assessments carried out in 2023, compared with almost 15,800 in 2019. This has resulted in: a backlog in new registrations of health and care providers delays in re-inspecting after a ‘requires improvement’ or ‘inadequate’ rating increasing age of ratings The review has concluded that poor operational performance is impacting CQC’s ability to ensure that health and social care services provide people with safe, effective and compassionate care, negatively impacting the opportunity to improve health and social care services, and, in some cases, for providers to deliver services at all. Conclusion 2: significant challenges with the provider portal and regulatory platform New IT systems were introduced at CQC from 2021 onwards. However, the deployment of new systems resulted in significant problems for users and staff. The review has concluded that poorly performing IT systems are hampering CQC’s ability to roll out the SAF, and cause considerable frustration and time loss for providers and CQC staff. Conclusion 3: delays in producing reports and poor-quality reports All sectors told the review that they can wait for several months to receive reports and ratings following assessments. The review has heard multiple comments about poor-quality reports - these have come from providers and from members of the public. Poor-quality and delayed reports hamper users’ ability to access information, and limit the credibility and impact of assessments for providers. Conclusion 4: loss of credibility within the health and care sectors due to the loss of sector expertise and wider restructuring, resulting in lost opportunities for improvement CQC underwent an internal restructuring in 2023, alongside the introduction of the SAF and new IT systems. The restructuring moved operational staff from 3 directorates with a focus on specific sectors into integrated teams operating at a local level, resulting in a loss of expertise. The review has found that the current model of generalist inspectors and a lack of expertise at senior levels of CQC, combined with a loss of relationships across CQC and providers, is impacting the credibility of CQC, resulting in a lost opportunity to improve health and social care services. Conclusion 5: concerns around the single assessment framework (SAF) and its application The SAF has set out 34 areas of care quality (called ‘quality statements’) that could be applied to any provider of health or social care with a subset applied to assessments of integrated care systems (ICSs) and local authorities. These align to the 5 domains of quality used for many years and referred to as ‘key questions’ within the SAF. For each of the 34 quality statements, there are 6 ‘evidence categories’. These are: people experience, staff experience, partner experience, observations, processes and outcomes. The review has identified 7 concerns with the SAF as follows: the way in which the SAF is described is poorly laid out on the CQC website, not well communicated internally or externally, and uses vague language there is limited information available for providers and users or patients as to what care looks like under each of the ratings categories, resulting in a lack of consistency in how care is assessed and a lost opportunity for improvement there are questions about how data on user and patient experience is collected and used more could be done to support and encourage innovation in care delivery there is insufficient attention paid to the effectiveness of care and a lack of focus on outcomes (including inequalities in outcomes) there is no reference to use of resources or the efficient and economic delivery of care, which is a significant gap there is little reference to, or acknowledgement of, the challenges in balancing risk and ensuring high-quality care across an organisation or wider health and care system Conclusion 6: lack of clarity regarding how ratings are calculated and concerning use of the outcome of previous inspections (that often took place several years ago) to calculate a current rating The review has learnt that overall ratings for a provider may be calculated by aggregating the outcomes from inspections over several years. This cannot be credible or right. Furthermore, providers do not understand how ratings are calculated and, as a result, believe it is a complicated algorithm, or a “magic box”. Ratings matter - they are used by users and their friends and family, they are used by commissioning bodies (the NHS, private health insurers and local authorities), and they drive effective use of capacity in the sector. They are a significant factor in staff recruitment and retention. Conclusion 7: there are opportunities to improve CQC’s assessment of local authority Care Act duties The Health and Care Act 2022 gave powers to CQC to assess local authorities’ delivery of their adult social care duties after several reports and publications identified a gap in accountability and oversight of adult social care. The review found broad support for the overall assessment framework but also heard feedback that the assessment process and reporting could be improved. Conclusion 8: ICS assessments are in early stages of development with a number of concerns shared The Health and Care Act 2022 introduced a new duty for CQC  to review and assess ICSs. Statute sets out 3 priority areas for CQC to look at: leadership, integration and quality of care; and the Secretary of State can set priorities on other themes. CQC developed a methodology for these assessments, which was tested in pilots in Dorset and Birmingham and Solihull, but wider rollout has been paused as a result of a number of concerns shared with the review. Conclusion 9: CQC could do more to support improvements in quality across the health and care sector The review heard a consistent comment that CQC should not be an improvement body per se, but, at the same time, could do more to support the health and care sectors to improve. It could do this, for example, through the description of best practice and greater sharing of new models of care delivery, leading international examples of high-quality care and more innovative approaches - particularly the use of technology. Governance structures within organisations are crucial to improvement. A greater focus on how organisations are approaching and delivering improvement, rather than looking at input metrics, could enable more significant improvements in quality of care. Conclusion 10: there are opportunities to improve the sponsorship relationship between CQC and the Department of Health and Social Care (DHSC) DHSC’s sponsorship of CQC should promote and maintain an effective working relationship between the department and CQC, which should, in turn, facilitate high-quality, accountable, efficient and effective services to the public. The review has found that DHSC could do more to ensure that CQC is sponsored effectively, in line with the government’s Arm’s length body sponsorship code of good practice. The review’s recommendations The health and care sector is one of the most significant drivers of health, public satisfaction and economic growth. It needs - and deserves - a high-performing regulator. In order to restore confidence and credibility and support improvements in health and social care, there is a need to: rapidly improve operational performance, fix the provider portal and regulatory platform, and improve the quality of reports rebuild expertise and relationships with providers review the SAF to make it fit for purpose with clear descriptors and a far greater focus on effectiveness, outcomes and use of resources clarify how ratings are calculated and make the results more transparent continue to evolve and improve local authority assessments formally pause ICS assessments strengthen sponsorship arrangements.

This review has been commissioned by the board of the Care Quality Commission (CQC) to complement the report by Dr Penny Dash, by looking at changes that CQC made following the publication of its new strategy in 2021 and their impact. Importantly, this review makes recommendations on solutions to CQC’s current problems. The transformation programme that followed the 2021 strategy had 3 key elements: A major organisational restructure. The introduction of a single assessment framework across all the sectors that CQC regulates (hospitals, mental health services, ambulances, primary and community care services and adult social care). The development of a new IT system, named the regulatory platform. These three initiatives are clearly interlinked, but this review has shown that all three have failed to deliver the benefits that were intended, despite being initially welcomed by providers.  Key recommendations from the review A fundamental reset of the organisation is needed. This needs to be akin to the reset in 2012/13, following the problems related to the regulator that were revealed by the report of the public inquiry into Mid Staffordshire NHS Foundation Trust (the Robert Francis inquiry) and the BBC investigation of Winterbourne View. The previous organisational structure should be re-instated as soon as reasonably possible. Chief inspectors should lead sector-based inspection teams at all levels. These teams can be brought together to assess integration of care across a local area, while retaining focus on their own specialism. The current Operations directorate should be disbanded and reformed into sector-based inspection directorates. Many of the staff currently working in the regulatory leadership directorate should be re-assigned to the relevant inspection directorate. At least three permanent Chief Inspectors should be appointed as soon as reasonably possible to lead the sector-based inspection directorates. Serious consideration should be given to the appointment of a fourth Chief Inspector to lead regulation of mental health services and to oversee inspections under the Mental health Act. Ongoing relationships between inspection staff with relevant skills and experience and providers should be re-instated as soon as possible. Regular dialogue coupled with appropriate levels of support and challenge in respect of required improvements has been sorely missed both by CQC staff and by health and social care providers. Aspects of the single assessment framework could be retained – with some modifications. Other aspects should be suspended and almost certainly scrapped, including the evidence categories and scoring system. More work needs to be done to define what good looks like in different services. Decisions on the future of the regulatory platform are outside the scope of this review. However, it is possible that simplifying the assessment framework (e.g. by scrapping evidence categories and scoring) may make it easier to resolve the problems with the IT system, but expert advice will be needed on this. The use of data to inform judgements should be given much higher priority than at present. Existing datasets already collected by NHS England and associated bodies should be incorporated into assessments of hospitals and primary care services as soon as possible. New data sharing agreements between national bodies should be instituted as soon as possible. Uniform availability of high-quality data/intelligence would reduce the burden on both CQC staff and providers. Staffing levels and pay scales within the inspection directorates should be reviewed as a matter of urgency. There are currently too few staff working in the hospital and primary care inspection programmes to undertake the duties of the regulator within reasonable timescales. The gap between NHS and CQC pay scales has almost certainly contributed to the loss of inspection staff. Priorities for inspection within the healthcare sectors need to be reviewed, given current staffing levels. Possible approaches to prioritisation are discussed in greater detail in later sections of this report. CQC should work closely in partnership with leaders of health care and adult social care to design improved approaches to assessment and inspection. This would be welcomed by those being regulated. They would also welcome a return to a larger element of peer review in the process. Further work to determine how the current backlogs in registration can be reduced or eliminated is urgently required. During the course of this review, the issue of “one-word ratings” was raised on numerous occasions by providers. Further consideration should therefore be given to this issue. In particular, the level at which ratings makes sense to people using services should be considered.