Our response to the CQC State of Care Report 2025/26

Dr Rosie Benneyworth, Interim Chief Executive said:

“The findings in this year’s State of Care report will resonate across the health and care system. While it is encouraging to see signs of improvement and examples of good practice, the report rightly highlights persistent challenges in access to care, workforce pressures, health inequalities and the growing complexity of people’s care needs. These are themes we continue to see across our investigation work, reinforcing that harm rarely stems from a single action or individual, but instead emerges from pressures, constraints and vulnerabilities within complex systems.

“The report’s focus on mental health is particularly significant. Our investigations have highlighted patient safety risks across mental health crisis care, inpatient settings, transitions between services and support for vulnerable patients in the community. We continue to examine how people access urgent mental health support, how services work together during periods of crisis, and how safety risks can arise when patients move between organisations or fall between parts of the system. These findings echo the concerns raised by CQC about growing demand, long waits, challenges in community provision and difficulties supporting people safely after discharge.

“Our investigations have consistently shown that staffing pressures affect much more than workforce wellbeing alone. They can influence communication, supervision, decision making, continuity of care and the capacity of organisations to learn and improve. Safe systems require the right people, skills and support to deliver care consistently under pressure. The CQC's findings reinforce the importance of viewing workforce issues as a patient safety issue as well as an operational one.

“We are also concerned by the challenges facing children and young people described in the report. We are currently investigating patient safety risks associated with delays in accessing child health community services, reflecting wider concerns about growing demand and long waits for support at critical stages of development. The experiences of children and young people illustrate the importance of timely access to care and effective coordination between services.

“The report explores the impact of health inequalities, and this is something we see through many of our investigations. They repeatedly highlight that people can experience different outcomes and higher levels of risk depending on where they live, how easily they can access services, and a range of social, cultural and demographic factors that can influence the care they receive. This is particularly evident in our investigation work relating to mental health, learning disabilities, long term health conditions, and maternity.

“The report highlights the renewed focus on adult social care and the issues we see in health settings during our investigations are apparent across both sectors. Difficulties with discharge and transitions of care, alongside poor information sharing and coordination between organisations. One of our most recently launched investigations looks at medication safety in care homes. This is an area that was raised with us due to recurring safety concerns that arise when multiple organisations and professionals need to work together to provide care. Improving safety therefore requires a whole-system perspective that extends beyond organisational boundaries.

“Many of the issues set out in the report are well understood – the challenge is always ensuring that learning is translated into meaningful and sustained improvement. Safety is a critical part of this and even when under immense strain, we believe that the system can learn and make care safer for patients and more sustainable for people who deliver it. The State of Care report always provides a vital call to action, shining a light on the biggest priorities in health and care and highlighting why innovation, a fundamental change in how we think about safety, and meaningful collaboration across the system are essential to improving outcomes for patients and the public.”