Inspection findings

Medical-centre ratings

Medical centres, 2025/26. Initial and follow-up groups have different purposes.

What CQC found: Of 11 first inspections, 9 were good, 1 required improvement and 1 was inadequate. All 15 follow-up entries were good overall; 12 had an updated key-question rating. Medical centres, Figures 1–2; Improvement on re-inspection. S14

Possible Defence lesson: Overall ratings and changes in individual quality questions are different measures. CHECK-14 concerns what inspection evidence actually establishes.

Medical-centre staffing, records and risk

Medical centres, 2025/26. Concerns were not quantified across every centre.

What CQC found: Leadership was generally positive. Staff gaps reduced governance capacity. Records and system interfaces remained concerns; an outage from mid-December 2025 to 13 February 2026 affected event reporting. Escalation did not always secure senior risk ownership. Medical centres, Information systems; Leadership capacity; Risk management. S14

Possible Defence lesson: Reporting continuity and senior ownership matter alongside local procedures. Relevant questions concern records and downtime, harm escalation, leadership and action closure.

Dental services

Dental centres, 2025/26. Standards judgements are not overall ratings; follow-ups covered the safe question only.

What CQC found: Of 17 comprehensive inspections, 13 met standards across all questions. Of 3 safety follow-ups, Pirbright met standards; Mount Pleasant and Waddington did not. Waddington's building constraints persisted after escalation because funding remained unapproved. Dental services, Figures 3–4; Infrastructure. S14

Possible Defence lesson: Escalating a concern and resolving it are separate outcomes. Questions about assurance and dependencies sit in CHECK-15 and CHECK-17.

South East mental-health network

South East mental-health network, December 2025. One network, visiting Woolwich, Aldershot and Portsmouth; findings do not cover the other networks.

What CQC found: Overall performance required improvement; caring was good. Most patients described supportive care but also long waits between referral, assessment and treatment. Defence community mental health services, inspection account and People's experience of the service. S14

The primary report detail below gives the waiting-time figures, reported causes and other findings. Positive care experiences and concerns in other quality domains can coexist. CHECK-14 concerns the range of evidence used in assurance.

Cyprus emergency care: annual account

British Forces Cyprus pre-hospital emergency care, December 2025 follow-up. One overseas service; the annual account does not specify every remaining concern.

What CQC found: CQC reported clearer Defence Primary Healthcare (DPHC) accountability, coordinated paramedic leadership and shared learning from adverse events. Further improvement was still required. Pre-hospital emergency care, December 2025 follow-up account. S14

Possible Defence lesson: The primary report detail below identifies the five recommendations. An improved arrangement is not proof that every concern is resolved. CHECK-17 distinguishes action completion from sustained effect.

Regional rehabilitation

Cosford and Portsmouth regional rehabilitation units, 2025/26. Two named units; do not infer a result for all units.

What CQC found: CQC found well-led teams providing safe, effective, caring and responsive care. Regional rehabilitation units, final findings paragraph. S14

Possible Defence lesson: Positive findings are part of the evidence base. CHECK-14 retains the service and inspection-method boundary.

Longer-term observations: 2017–2026

Medical centres, programme-wide observations from 2017–2026. These are not quantified annual prevalence findings.

What CQC found: CQC reported better safeguarding information-sharing and central complaint visibility. Manual test-result arrangements remained vulnerable to IT problems, missing cover and learning that was not embedded. Impact, Safeguarding; Complaints management; Managing test results in medical centres. S14

Possible Defence lesson: The relevant distinction is between recording information and ensuring a reliable response. See CHECK-04, CHECK-05 and CHECK-06.

Treatment waits and their reported causes

CQC recorded 218 patients waiting for treatment. The longest reviewed waits were 44 weeks for core group treatment and 33 weeks for enhanced therapy. These are longest waits, not averages or current waiting times. Earlier October figures could not be confirmed as accurate. S45, p.19

The report identifies several contributors to delay:

• No target covered the time from assessment to treatment.
• Anxiety and mood groups ran twice a year, with no rolling programme.
• Enhanced therapy depended on clinician availability. Managers could not confirm the accuracy of weekly capacity information.
• Allocation could involve up to five meetings. Staff were uncertain which meeting should make some decisions. S45, pp.15–16, 19

Staff lacked reliable waiting-time information to share with patients. Primary care colleagues managed patients while they waited, but there was no defined primary-care review interval. Staff also described uncertainty about who owned waiting-list risk. This was not a complete absence of monitoring: the report records waiting-list managers and monthly audits against a 90-day patient-contact requirement. S45, pp.8, 19

Safety and leadership concerns

Medicines prescribing, audit and training arrangements were inconsistent. Staff did not always recognise or report incidents, and learning from investigations was not evident across the network. Delayed requests for death reviews reduced the opportunity for early learning. S45, pp.10–11

CQC found unclear accountability, stretched management capacity and limited senior visibility. Audits and meetings did not reliably produce clear actions, named owners or evidence of improvement. Some staff reported unresolved concerns about colleagues' behaviour, although many felt respected by local managers. S45, pp.21–25

Positive findings and what they mean for Defence

Patients described compassionate care and involvement in decisions. Safeguarding arrangements worked well, and transfers between departments had clear monitoring responsibilities. These positive findings form part of the same inspection account. S45, pp.8, 17, 19

Possible Defence lesson: an assurance picture needs patient experience, reliable access data, clear responsibility for patients who wait, and evidence that improvement actions work. The separate internal questions concern harm escalation, leadership, inspection evidence and completed improvements. This is a provisional comparison, not a finding about other services or current internal policy.

Has CQC confirmed later resolution?

No later outcome or closure report was identified in the official CQC directory and targeted CQC/MOD searches checked on 8 October 2026. This does not establish that the December findings persist today. The inspection also predates the final Thirlwall report, so it cannot demonstrate implementation of its recommendations. The follow-up limit is recorded in VAL-009. S45

Vehicle cleaning

Routine cleaning checks had improved, but a provider for scheduled deep cleaning had not been secured. Interim deep cleans took place on an ad hoc basis. CQC recommended further work on infection prevention, including vehicle deep cleaning. S44, pp.5, 9–11

Clinical oversight of long-term locums

Recruitment checks had improved. Long-term locum paramedics still lacked appraisal and continuing professional development arrangements. CQC recommended processes to maintain their clinical oversight. S44, pp.5, 30

Protected time for clinical leaders

Lead paramedics lacked protected leadership time after December 2025 and were expected to crew vehicles. CQC recommended implementation of the business plan, with particular attention to time for leadership duties. S44, pp.5, 11, 28

Working hours at Episkopi

CQC reported that Episkopi medics worked hours above the limits in the specified Defence Instruction and Notice. It recommended that staff hours comply with that instruction. This records CQC's finding; it is not an independent determination of an employment-law breach. S44, pp.5, 11–12

Emergency dispatch

CQC identified problems with prioritising calls, locating patients and dispatcher training. It recommended stronger dispatch processes, prioritisation and location accuracy. Planned changes were not established outcomes at the inspection. S44, pp.5, 12, 19–20

What this adds to the Defence reference

Possible Defence lesson: an improved overall rating can coexist with specific unresolved safety concerns. Clear responsibility, staffing capacity and evidence that actions work remain separate questions. Relevant internal questions are CHECK-13 — Leadership, CHECK-14 — Inspection and CHECK-17 — Completing improvements.

Later resolution: not established in the official CQC and MOD sources checked on 7 October 2026. The July annual account still records a need for improvement. This does not establish that every December finding remains unresolved today. The inspection predates the final Thirlwall report and cannot demonstrate implementation of its recommendations. S14 S44

Staffing and supervision

Inspection evidence: Cyprus lacked appraisal and professional development arrangements for long-term locums, and protected time for clinical leaders. South East management capacity was stretched. S44, pp.5, 28, 30; S45, pp.21–22

Existing requirement: Article 3003(1) requires enough suitably qualified and experienced staff to meet patient needs and regulatory requirements. Article 3003(2)(a) requires the support, training, professional development, supervision and appraisal necessary for staff duties. S11, p.30

Separate internal question — CHECK-13: Who confirms that leaders have time for safety responsibilities and that locums receive the oversight and development their duties require?

Incident reporting and risk ownership

Inspection evidence: South East staff did not always recognise or report incidents. Staff also described unclear responsibility for waiting-list risk, although monitoring arrangements existed. S45, pp.8, 10–11

Existing requirement: Article 1004(1) requires systems to report the specified incidents immediately. Article 3002(2)(b) requires systems to assess, monitor and mitigate risks. Article 1002(1)(a) requires terms of reference for the Responsible Person; these should include risk-management responsibility. The report does not establish which unreported incidents met Article 1004's criteria. S11, pp.11, 13–14, 29

Separate internal question — CHECK-06 and CHECK-13: Who owns risk for patients awaiting treatment, and who confirms that incidents meeting notification criteria reach the required recipients without delay?

Evidence that corrective action works

Inspection evidence: Cyprus had improved, but some planned changes had not yet shown their effect. South East meetings and audits did not reliably produce clear actions or improvements. S44, p.5; S45, pp.23–25

Existing requirement: Article 3002(1) requires compliance systems to operate effectively. Article 3002(2)(a) requires systems to assess, monitor and improve service quality and safety. These clauses do not prescribe a particular action-closure form. S11, p.29

Separate internal question — CHECK-17: What evidence shows that an action improved safety, who can approve closure, and how is sustained effect checked?