Right support, right care, right culture
How CQC regulates providers supporting autistic people and people with a learning disability
- Model of care and setting maximises people's choice, control and independence
- Care is person-centred and promotes people's dignity, privacy and human rights
- Ethos, values, attitudes and behaviours of leaders and care staff ensure people using services lead confident, inclusive and empowered lives
Autistic people and people with a learning disability are as entitled to live an ordinary life as any other citizen. We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted.
We are the quality and safety regulator of health and social care services in England. Under section 3 of the Health and Social Care Act 2008 our objective is to protect and promote the health, safety and welfare of people who use health and social care services. We encourage providers to develop services for people that comply with national policy and current best practice:
- Service model
- Building the right support
- Building the right home
- Learning disabilities and behaviour that challenges: service design and delivery NG93
Our position on the size of residential services
People who use services have told us they want a stronger focus on outcomes for people. We have listened to this feedback and it has been the driving force behind the changes we have made to this guidance. Our main concern is the quality of life people are able to experience and the care they receive, and this will continue to be case.
This guidance has always been set alongside other standards in the system and we continue to maintain that link. This includes NICE guidance (CG142) on the definition of 'small' services for autistic people with mental health conditions and/or behaviour 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)". Our review into restraint, prolonged seclusion and segregation for people with a mental health problem, learning disability or autistic people supports this and, for people currently in the hospital system, this is likely to require commissioners and providers to develop bespoke services.
For people with a learning disability and behaviour that may challenge, NICE guidance (NG93) recommends people should have the option to "live alone with appropriate support if they prefer this and it is suitable for them. If adults prefer not to live alone with support, or it is not suitable for them, offer them the option of living with a small number of other people in shared housing that has a small-scale domestic feel. Involve people in choosing how many people, and who, they live with."
While we continue to refer to NICE guidance in describing what 'small' means for how we apply our approach, we want to be clear that this is not the same as having an absolute upper limit for the size of services. CQC has never applied a six-bed limit in its registration or inspection assessments.
We have previously refused to register services that are smaller than six beds because they could not assure us that they could deliver person-centred care in line with current best practice. We have also registered services with more than six beds because they have been able to demonstrate how care will be high quality and person-centred.
We will continue to consider the size and design of residential settings as part our assessments, alongside other considerations.
We will only register, and favourably rate, services that allow people's dignity and privacy to be maintained and that facilitate person-centred care. This must be in line with current best practice guidance and not be developed as new campus or congregate settings.
In our experience of registering and inspecting these types of service, the larger a service is, the harder the provider will need to work to clearly demonstrate it delivers high-quality, person-centred care. This guidance sets out in detail what that person-centred care needs to look like. It is unlikely that services that are not similar to ordinary residential accommodation will be registered.
Purpose of this guidance
This guidance is statutory guidance in accordance with s.23 of the Health and Social Care Act 2008.
- 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 our regulatory approach for these services, covering our registration, inspection, monitor and enforcement functions
- makes our expectations clear to future and existing providers.
We will use this guidance in our assessments and judgements to promote consistency. However, we will base each assessment and judgement on the evidence presented in that case.
We will always take appropriate regulatory action if:
- people's needs are not being met, or
- providers cannot demonstrate they can care for people in a way that is person-centred, and promotes choice, inclusion, control and independence.
We encourage providers to discuss their proposals or development ideas with us before submitting an application or making changes to services. This can help providers make an informed decision about whether plans are likely to comply with this guidance.
- In this guidance, 'people' means autistic people and those with a learning disability. 'Services' means the provision of care and support to meet people's individual needs within the scope of regulated activities. These activities are delivered by providers that are registered with CQC typically, but not exclusively, in the settings described in our service type guidance.
- The National Service Model, Building the right support, Building the right home and other key national policy and good practice guidance (see Background section for further information)