Recommendation 27

Promoting effective enforcement

The healthcare systems regulator should promote effective enforcement by: use of a low threshold of suspicion; no tolerance of non-compliance with fundamental standards; and allowing no place for favourable assumptions, unless there is evidence showing that suspicions are ill-founded or that deficiencies have been remedied. It requires a focus on identifying what is wrong, not on praising what is right.

The Care Quality Commission’s new approach to inspection includes clearly recognising and encouraging high quality care through ratings which will highlight outstanding practice. But where it identifies concerns, the Care Quality Commission will also have the ability to act swiftly and firmly on it.

The Department of Health will consult shortly on new regulations which will make clearer the fundamental standards of care, and enable enforcement against them without a prior warning notice. Subject to parliamentary approval, the regulations will come into force during 2014. The Care Quality Commission will consult on a new enforcement policy for all sectors, making clear how any breach of the fundamental standards of care will be acted upon, so that these new regulations can be enforced effectively as they come into effect. Through its policies, the Care Quality Commission will ensure its actions are as transparent and understandable to the public as possible, and that information is made available about providers subject to enforcement.

For NHS Trusts and NHS Foundation Trusts there is a single failure regime to ensure that the various means of holding NHS providers to account for failures of finance or governance are equally available for failures of quality. It ensures that the Chief Inspector of Hospitals’ concerns trigger action by commissioners, the NHS Trust Development Authority or Monitor, rather than the Care Quality Commission acting alone. The action triggered includes credible strong sanctions, such as a managed process for placing a provider into administration and reconfiguring its services.

While this new approach to effective action in the NHS has already started, it will be further underpinned by legislation upon adoption of the Care Bill, currently before Parliament. The new legislation will strengthen the current administrative arrangements and give a statutory basis for the means by which, through the Chief Inspector, the Care Quality Commission refers a foundation trust to Monitor for intervention.


New Fundamental Standards regulations come into force for all providers of health and social care in April 2015. The Care Act 2014, which received Royal Assent in May 2014, created an additional form of warning notice specifically for NHS trusts and foundation trusts, which the Care Quality Commission can issue when it judges that a trust requires significant improvement. This warning notice can lead to the provider entering the failure regime and is intended to come into force at the same time as the fundamental standards are introduced.

Special measures will apply to NHS trusts and foundation trusts that have serious failures in quality of care and where there are concerns that existing leadership cannot make the necessary improvements without support. NHS trusts are put into special measures by the NHS Trust Development Authority while foundations trusts will be put into special measures by Monitor.

Generally, this happens following a recommendation by Professor Sir Mike Richards, Chief Inspector of Hospitals. In May 2014, the Care Quality Commission, Monitor and the NHS Trust Development Authority published joint guidance on how the special measures programme works for NHS trusts and Foundation Trusts.  The guidance explains why a trust would be placed in special measures, what happens during the special measures period, the roles and responsibilities of the Trust, the Care Quality Commission, Monitor and the NHS Trust Development Authority, and how trusts exit special measures.