The Care Quality Commission fears it will “almost certainly” not identify failure, leading to “persistent poor quality care for users”, as a result of government reforms and reduced efficiency.

The regulator is carrying out a series of reviews into its systems, papers for its board meeting last week revealed.

A risk register showed the CQC is concerned it will “almost certainly” face a scenario in which it “fails effectively to identify or deal with non-compliance leading to persistent poor quality care for users and reputational damage”.

The possibility is red-rated and classed as a “major” risk that “almost certainly will occur”.

The CQC board has established a working group, due to report in September, to examine whether the regulatory model is “sufficiently sustainable to deal with foreseeable changes in the policy environment”.

Chief executive Cynthia Bower is leading five separate reviews into the organisation’s workforce, operations, management function and joint licensing arrangements with Monitor.

She is also looking into whether the CQC is able to identify and deal with non-compliance with its standards, while delivering the “significant” task of registering 9,000 GP practices by April 2012.

Ms Bower last week told the Mid Staffordshire Foundation Trust public inquiry that the CQC could ask the government to reduce its remit if it finds it cannot cope with registering GPs and dentists.

She admitted the task would be a struggle and said that if it became unrealistic the regulator would ask for further funding from the Department of Health.

“If the DH responds ‘no’,” she said, “we would have to explain what the regulator could do within the resource envelope.”

The board papers said the CQC had already proposed changes to its plans for GP registration to the DH, to “improve the process for GPs, and to give CQC more opportunity to embed compliance monitoring in the sectors we already regulate”.

Meanwhile, the CQC identified a further “major” risk that it will lack the necessary resources to meet the demands being placed on it, leading to unacceptable levels of performance.

Ms Bower is examining whether the organisation can meet its commitment to review every provider by next October.

Another source of pressure is coming from the 155 applications being received by the CQC on average per day from adult social care, independent healthcare and NHS providers wishing to vary their registration.

There are 112 applications “on hold” awaiting information from providers or due legal or financial complications.

A CQC spokesman said the regulator sought to identify and mitigate risks, and to be open in the reporting of risks.

He said: “Assigning a ‘red risk’ to an issue is not an expectation of failure, but a way of providing internal assurance that the consequences of potential failure have been recognised and that there are appropriate procedures in place to mitigate this.”

Mid Staffordshire: a question of competence

The competence of CQC inspectors was defended by chief executive Cynthia Bower in her second appearance at the Mid Staffordshire Foundation Trust inquiry.

She was the last of four witnesses from the CQC to give evidence to the inquiry, which is examining the role of regulation in the NHS and why failings at the trust were not spotted sooner.

Inquiry counsel Tom Kark QC questioned how effective CQC inspectors, who include “ex-detective constables”, could be at assessing trusts, when few of them had clinical backgrounds.

Ms Bower said all staff were trained in regulation and revealed the board had decided against a model with teams built around specialist areas rather than regions because of the huge range of health and social services the CQC had to regulate.

She added: “Just to have someone who’s qualified as a nurse or a doctor 10 years ago and has worked with the regulator doesn’t necessarily mean that they’re entirely up to date with the latest practices in that particular field.”

Ms Bower defended the decision to abolish the investigations team – a central resource sent into troubled organisations, such as Mid Staffs – that existed under its predecessor organisation the Healthcare Commission. Ms Bower said it was “partly a resource issue and partly a philosophy issue” in order to devote as much resource as possible to the front line.