Health and social care watchdog reveals its refreshed guidance on autism and learning disability

Earlier this month, CQC published revised guidance on its policy approach to regulating providers supporting autistic people and people with a learning disability. Right support, right care, right culture is the new updated version of Registering the right support.

Since its publication in 2017, the policy landscape has continued to evolve with the regulator adopting a firmer approach to the registration and variations of registration of providers who support autistic people and people with a learning disability.

Last year, CQC decided to review Registering the right support, so carried out an engagement exercise to explore with a range of stakeholders how they could make improvements to it. The revised guidance is in two parts:

• What the CQC expect good care to look like for people with a learning disability and autistic people; and
• Case studies mainly based on decisions CQC has made about registration applications and in their monitoring and inspections

There is a greater focus on outcomes with health and social care providers assessed across three ‘domains’ – whether they are providing the: right support, right care and right culture. Both new and existing providers will need to meet these criteria.

The CQC describe these as follows:

• Right support: the model of care and setting maximises people’s choice, control and independence.

• Right care: the care is person-centre and promotes people’s dignity, privacy and human rights.

• Right culture: the ethos, values, attitudes and behaviours of leaders and care staff ensure people using services lead confident, inclusive and empowered lives.

CQC explain the new guidance:

• Applies to any service that currently, or intends to, provide regulated care to autistic people and people with a learning disability. This includes children and young adults, working age adults and older people.

• Describes CQC’s regulatory approach for these services, covering the registration, inspection and its monitoring and enforcement functions.

• Makes CQC expectations clear to future and existing providers.

CQC will be using this statutory guidance (in accordance with section 23 of the Health and Social Care Act 2008) in their “assessments and judgements to promote consistency” – and say that they will base each assessment and judgement on the “evidence presented” in that case.

Providers of new and existing services will need to demonstrate they are meeting the requirements – and to assist providers CQC identify the key aspects of what they will look for in a service, as follows:

• CQC characteristics of ratings for good in healthcare and adult social care
• The regulations, including the fundamental standards
• People’s expectations as set out in the service model
• The requirements in Right support, right care, right culture to demonstrate that: 

• • There is a clear need for the service and it has been agreed by commissioners
  • The size, setting and design of the service meet people’s expectations and align with current best practice
  • People have access to the community
  • The model of care, policies and procedures are in line with current best practice 

But what about the rule of six? What does the CQC say about the size of residential services – an issue that providers felt was not adequately addressed in the earlier iteration of the guidance with concern that six was the magic number of residents within each setting.

The CQC say that this guidance has always been set alongside other standards in the system – and this includes, NICE guidance (CG142) on the definition of ‘small’ services for autistic people with mental health conditions and/or behaviours that challenges. This states that residential care “should usually be provided in small, local community-based units (of no more than six people and with well-supported single person accommodation)”. CQC add that their review into restraint, prolonged seclusion and segregation for people with a mental health problem, learning disability or autistic people supports this approach while recognising that this is likely to require commissioners and providers to develop specialist services.

CQC explain that while they continue to refer to NICE guidance in describing what “small” means for how they apply their approach, they want to be clear that “this is not the same as having an absolute upper limit for the size of services.” It says that CQC has never applied a six bed rule limit in its registration or inspection assessments.

Appendix A of the guidance includes case studies illustrating Right support, right care, right culture in action, with examples of where they have registered services with more than six beds because it says they have been able to demonstrate how care will be high quality and person-centred. There are also case studies of where they have refused to register services that are smaller than six beds because providers could not assure CQC that they could deliver person-centred care in line with current best practice.

CQC is clear that they will only look to register – and favourably rate – those services that allow people’s dignity and privacy to be maintained and that provide for person-centred care. The regulator explains that it is unlikely that services that are not similar to ordinary residential accommodation will be registered – and equally, providers should not look to develop “new campus or congregate settings”.

Comment

We welcome CQC's greater clarification on their approach to size of residential services. In the last year or two we have seen the CQC register services designed to support eight or nine service users.

Providers looking to register new or expand existing services will now need to reflect in detail on the new guidance. CQC “encourage” providers to discuss their proposals or development ideas with them before submitting an application or making changes to services – you can access the email address here. While it is open to providers to appeal CQC decisions at the first-tier tribunal providers may be interested to read tribunal comments at Appendix A where appeals have been dismissed.

But will providers see the revised policy as sufficiently different to its previous iteration?

Professor Martin Green OBE, Chief Executive of Care England, commenting on the guidance says:

“Although we welcome the redrafted guidance, more could be done to demonstrate the importance of evidence in the revised approach. Care providers need to know that decisions made around the regulation of their services are evidence-based.”

In Care England’s consultation response in January, it sought to "highlight several key themes which it felt the draft guidance did not adequately address, including: size of services; commissioning; use of case studies; and how CQC applies the policy. Care England has reiterated these issues through further stakeholder meetings with CQC in advance of the final publication of their revised guidance."

Professor Green continues:

“We implore CQC to adopt a greater degree of transparency with the sector as to their own approach. This will foster a dynamic process whereby providers are fully able to understand the basis upon which decisions regarding services are made.”

Duncan Astill and Amanda Narkiewicz