Evidence given to the Mid Staffordshire Foundation Trust public inquiry by Care Quality Commission board members was “aspirational” and did not reflect what was happening in practice, the inquiry has heard.

An internal review document, leaked to the inquiry, sets out 24 points where evidence given by witnesses did not match what happens on the ground.

The inquiry heard the review was ordered by head of operational intelligence Sampana Banga after a number of regional intelligence and evidence officers (RIEOs) raised concerns about how their role had been described in evidence to the inquiry.

The review was carried out by senior operations analyst Rona Bryce, who was later threatened with suspension when the document was leaked.

Ms Bryce told the inquiry this week she had found the CQC evidence in May to be “aspirational” but insisted the review, carried out in the shadow of the Winterbourne View scandal, was intended to be “constructive”.

Discrepancies included the use of engagement forms, which CQC chair Dame Jo Williams told the inquiry were filled out to record all local engagement, including with whistleblowers. Dame Jo said this, combined with inspectors having their “ear to the ground” and checking sources such as local newspapers, meant the CQC would have picked up issues at Mid Staffs sooner than the Healthcare Commission.

However, an audit of how information passed to CQC inspectors by public led local involvement networks was recorded found the “majority” of contacts were not recorded using an engagement form. This meant the information would not be included on an organisation’s quality risk profile and the RIEOs, whose job is to review and analyse data on organisations to provide support to inspectors, would lack a true picture of which organisations were most at risk.

The inquiry also heard from South West based RIEO Lauren Goodman, who contributed to the internal review.  She contradicted evidence from director of intelligence Richard Hamblin that RIEOs “constantly reviewed” quality risk profiles, saying they updated them once a month “at best” due to the pressure of workload Ms Goodman is responsible for 837 care homes and nine NHS trusts.

Ms Bryce told the inquiry she had originally been told the CQC would correct the discrepancies in its evidence during its closing statement to the inquiry. However, a letter from the regulator’s solicitor states the CQC views it as “unfortunate” the matter had been referred to the inquiry and that any discrepancies are due to inconsistencies in implementation across the country.

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