Improving hospitals from ‘Inadequate’ to ‘Good’ CQC ratings

When the Care Quality Commission (CQC) rates a hospital service “Inadequate”, it is more than a regulatory judgement, but a signal of systemic risk. For organisations, it can trigger significant reputational damage, operational pressures, emergency improvement plans, and intense scrutiny. For staff, it can be deeply demoralising. And for patients and families, it raises fundamental questions about safety, trust and accountability.

But inadequate does not mean irrecoverable. Across England, many NHS trusts have demonstrated that with the right leadership, culture change, investment, and governance systems, it is entirely possible to move from inadequate to requires improvement, good, and in some cases outstanding.

One recent example comes from Hull Royal Infirmary’s emergency department, which has progressed from an “Inadequate” rating to “Requires Improvement” following its 2025 CQC inspection, demonstrating a positive shift, though significant concerns remain. Their journey reflects both the challenges and opportunities facing hospitals working to rebuild safety, culture and quality.

In this blog, Dr Richard Dune explores what an “Inadequate” rating means, how the CQC reaches this judgement, and, most importantly, how hospitals can turn poor ratings into catalysts for real, lasting improvement.

Understanding the CQC ratings system

The CQC rates health and social care services in England using four levels:

1. Outstanding
2. Good
3. Requires Improvement
4. Inadequate. 

An “Inadequate” rating indicates that a service is failing to provide care that is safe, effective, caring, responsive or well-led; the five key CQC assessment framework categories.

An inadequate rating may reflect:

• Serious or widespread patient safety risks

• Poor standards of treatment or care

• Persistently unsafe staffing levels

• Ineffective safeguarding processes

• Poor leadership, governance or culture

• Weak infection prevention and control (IPC)

• Medicines management failings

• Incomplete or outdated risk registers

• Lack of learning from incidents

• Significant breaches of the Health and Social Care Act 2008 Regulations. 

When a service is rated inadequate, the CQC may:

• Place it into special measures

• Require urgent remedial action

• Increase inspection frequency

• Mandate improvement plans

• Issue warning notices or enforcement action. 

The bar for “Inadequate” is set deliberately high, signalling that patients are at risk, and that leadership systems are not sufficiently robust to identify, mitigate or resolve that risk.

How the CQC arrives at an ‘Inadequate’ rating

Under the CQC assessment framework, inspectors review evidence across five domains:

1. Safe - Are people protected from abuse and avoidable harm?
2. Effective - Is care evidence-based, outcomes-driven and delivered by competent staff?
3. Caring - Do staff involve people, show compassion and maintain dignity?
4. Responsive - Are services organised to meet people’s needs?
5. Well-led - Is there effective leadership, culture, governance, risk management and learning?

A service may be rated inadequate under one domain or across several. Crucially, if the “Well-led” domain is inadequate, this often drives a poor overall rating, because failures in leadership and governance affect every other aspect of care.

The CQC uses multiple evidence sources:

• Observations of care

• Interviews with staff and patients

• Reviewing records, incidents, complaints and audits

• Triangulating safety data

• Listening to whistleblowers

• Assessing culture, leadership and governance systems

• Reviewing staffing rotas, training compliance and skill mix

• Examining medicines management, IPC and environmental standards

• Analysing wait times, patient flows, outcomes and backlogs. 

An “Inadequate” judgement is made when risks are systemic, persistent, poorly managed or unrecognised.

Hull Royal Infirmary ED: A case study in improvement

Hull Royal Infirmary’s emergency department was previously rated inadequate. In its 2025 inspection, the CQC noted significant improvements, including:

• Better triage and initial assessment

• Improved complaint handling

• Stronger communication with patients and families

• Leadership changes that were “driving improvements”

• Progress in caring: now rated “Good”. 

However, persistent breaches remained in:

• Safe staffing

• Medicines management

• Infection prevention and control

• Environmental safety

• Consent and documentation

• Cleanliness

• Governance and oversight. 

This mix of progress and continuing risk is typical of hospitals moving out of an inadequate rating. It demonstrates that improvement is possible, but also fragile.

So, how can hospitals consolidate progress and move further towards good or outstanding?

How hospitals improve from an ‘Inadequate’ CQC rating: A practical blueprint

Below are 7 actionable steps that hospitals can take to move from adequate to good CQC ratings:

1. Strengthen leadership and governance

Every sustainable improvement starts with leadership. The CQC repeatedly finds that inadequate services lack:

• Clear accountability

• Transparent decision-making

• Effective risk management

• Oversight of quality and performance

• Clinical leadership presence

• Psychological safety for staff.

How to strengthen governance and leadership

Actionable steps:

• Establish a unified leadership team with credibility and visibility

• Strengthen governance committees and reporting lines

• Introduce daily safety huddles and weekly quality meetings

• Ensure board-to-ward and ward-to-board visibility

• Refresh the risk register and ensure actions are monitored

• Strengthen Datix use, incident investigation and learning.

Governance improvement is not merely structural; it is cultural.

2. Focus relentlessly on safety essentials

Inadequate services often struggle with the basics:

• Staffing ratios

• Skill mix

• Medicines management

• IPC compliance

• Environmental safety. 

These are not optional extras, but foundational conditions for safe care.

How to improve patient safety

Actionable steps:

• Deliver safe staffing plans based on acuity and demand

• Audit and tighten medicines governance

• Rapidly address IPC shortfalls (cleanliness, PPE, isolation, hand hygiene)

• Simplify escalation processes

• Ensure safeguarding policies are current and embedded

• Introduce “back to basics” campaigns with daily monitoring. 

Hospitals that improve do so by mastering the fundamentals before tackling innovation.

3. Build workforce stability and training capacity

CQC inspection reports for inadequate services consistently highlight:

• High turnover

• Over-reliance on temporary staffing

• Poor training compliance

• Lack of supervision

• Burnout. 

Sustainable improvement requires a workforce that is:

• Well-staffed

• Well-trained

• Well-led

• Well-supported.

How to improve workforce retention

Actionable steps:

• Create workforce retention plans

• Improve access to supervision, mentorship and preceptorship

• Invest in statutory and mandatory training (including digital readiness)

• Expand specialist training for high-risk areas

• Implement wellbeing and burnout reduction programmes. 

You cannot improve care quality without improving the conditions in which staff work.

4. Embed quality improvement as a routine practice

Hospitals that rise from inadequate share a common attribute: embedded quality improvement (QI) capability.

QI must be:

• Continuous

• Staff-led

• Data-driven

• Engaged at every level. 

How to embed quality improvement

Actionable steps:

• Develop QI champions across departments

• Train staff in QI methodologies (PDSA cycles, driver diagrams, RCA)

• Use real-time dashboards to identify risks early

• Improve complaints and compliments loops

• Share learning across wards, teams and partner organisations. 

QI is not an initiative; it is a culture.

5. Improve patient experience and communication

The CQC emphasises the caring and responsive domains. Even high-performing clinical teams can struggle with:

• Communication gaps

• Long waits without updates

• Lack of dignity

• Inconsistency of information. 

How to improve patient experience and communication

Actionable steps:

• Introduce patient liaison teams in high-pressure areas

• Train staff in compassionate communication

• Improve signage, wayfinding and accessibility

• Co-design services with patients and carers

• Ensure patient experience data feeds directly into governance. 

Patient experience is a sensitive indicator of organisational culture.

6. Strengthen multi-agency and system collaboration

The CQC increasingly focuses on system working. Emergency departments do not operate in isolation; they are shaped by:

• Ambulance services

• Primary care

• Mental health crisis pathways

• Social care capacity

• Community services. 

How to strengthen multi-agency systems 

Actionable steps:

• Establish joint escalation protocols with partners

• Improve discharge planning procedures

• Strengthen relationships with ICSs, local authorities and community teams

• Use shared data platforms to improve flow. 

No ED can achieve excellence alone.

7. Monitor, review and sustain progress

Improvement is not a one-off project; it is an ongoing discipline.

To avoid sliding back:

• Track KPIs weekly and monthly

• Maintain oversight through board subcommittees

• Conduct regular audits, peer reviews and walkarounds

• Reinforce training and supervision cycles

• Celebrate improvements, however small

• Address slippage early. 

Consistency is the bridge between improvement and excellence.

Final reflections: Improvement is possible, but it must be protected

Hull Royal Infirmary’s emergency department shows that inadequate is not the end of the story. Progress, even significant progress, is achievable. But it is also fragile. Sustained improvement requires:

• Strong leadership

• Tight governance

• Stable staffing

• Investment in basics

• Clear communication

• Culture change

• System collaboration. 

And above all, a commitment to learning, reflection and accountability.

For organisations rated inadequate today, the message is clear: with the right support, improvement is possible. For those rated ‘Requires Improvement’, the challenge is to stay the course. And for those rated good or outstanding, vigilance is essential.

At The Mandatory Training Group, we support organisations in strengthening governance, developing their workforce, and meeting regulatory expectations. Our ComplyPlus™ Regulatory Compliance Management Software helps teams stay inspection-ready with digital policies, automated training compliance, audit trails, incident reporting and real-time dashboards, giving providers the structure and visibility needed to sustain improvement.

Downloadable resource

Download the Improving from an ‘Inadequate’ to a ‘Good’ CQC rating checklist to support your work in addressing systemic risks, unsafe care and weak governance that lead to inadequate CQC ratings.

Reference

BBC News (2025). Hospital improves rating, but concerns remain.