Monitoring questions for independent services for people with a learning disability and/or autism

Page last updated: 12 May 2022
Organisations we regulate

During the monitoring call our inspector will focus on these specific key lines of enquiry. You can open the questions to see the type of detail they will be interested in.


S1: How do systems, processes and practices keep people safe and safeguarded from abuse?
  • Are infection risks to people using the service being thoroughly assessed and managed?
  • Have changes been made to the layout/environment of clinical and non-clinical areas to continue to provide services safely in this period? (for example, clean sites, vehicle layout, separate entrances and waiting areas for known/suspected COVID patients, additional signage, spaces between stations, isolation facilities, ensuring compliance with best practice guidance when visiting people in their own homes etc.).
  • Does the service have the resources to obtain, and reliable access to, all the supplies, personal protective equipment and COVID-19 testing it needs, for both staff and, where appropriate, people who use the service?
  • Are working arrangements and procedures clear and accessible to staff, people who use the service, their supporters and, where appropriate, visitors to the service?
  • Are people using the service being protected from abuse, neglect, discrimination, and loss of their human rights?
  • Where applicable, has the service identified when it may be depriving a person of their liberty, and followed the correct and lawful procedures? (for example, DoLS application, Court of Protection)
  • Are the service’s safeguarding and other policies and practice, together with local systems, properly managing any concerns about abuse and protecting people’s human rights? Is the service working effectively with local authority safeguarding teams?
  • Regarding ‘closed cultures’, do you audit/quality assure the culture in the service or do you know how you might do this? Are you aware of CQC’s guidance on closed cultures?
  • Is the service maintaining mandatory staff training to keep people safe?
  • How are the Registered Manager and Registered Provider assured that patients do not suffer abuse in the service?
  • Are there regular visits from other stakeholders, visiting professionals or families and friends to the service?
  • Have there been any concerns raised during quality or contracting visits by commissioners or safeguarding teams? How has the service responded to these?
  • Have there been any concerns raised by family members or people using the service? How has the service responded to these?
S2: How are risks to people assessed, and their safety monitored and managed, so they are supported to stay safe?
  • Are risks to the health and wellbeing of people using the service being properly assessed, monitored, and managed?
  • Are there enough staff with the skills and experience to provide safe care and treatment in a dignified and respectful way? Are escalation plans in place in response to surges in demand, for example, second wave, seasonal pressures?
  • How is the service identifying and managing risks for people using the service, including any restrictive practices and their impact on the person, or issues affecting their legal or human rights?
  • Where restrictive practices are in place, are there plans to reduce restrictions to a minimum level?
  • Do staff have specific training to support people with a learning disability and/or autistic people?
S3: Do staff have all the information they need to deliver safe care and treatment to people?
  • Does the service have access to and is it following guidelines around Treatment Escalation Plans (TEPs), anticipatory care planning, Do Not Attempt CPR(DNACPR) orders and individualised care plans? Are plans in place for rapid transfer to preferred places of care – relationships and planning with PMS, district nursing etc?
  • Is the service able to effectively manage referrals and, where relevant, discharges, and ensure safe transfers of care? Where relevant, what are the testing arrangements, and how does the service handle transfers of known/suspected COVID patients safely? How is the service working with other partners?
  • Do people have access to individualised care plans, including positive behaviour support plans, treatment escalation plans and anticipatory care planning?
  • Does the service have systems to ensure people have access to primary and specialist healthcare services? Is information shared to ensure that planned care meets the physical health needs of people using the service?
  • Are local arrangements in place for the safe transfer of patients to an acute hospital where this is necessary to meet their physical health needs?
  • Where Do Not Attempt CPR (DNACPR) orders are in place, do these follow current guidance?
S4: How does the provider ensure the proper and safe use of medicines, where the service is responsible?
  • Are medicines being managed safely and effectively? Has COVID-19 affected the service’s ability to manage medicines?
S5: What is the track record on safety?
  • Are there any significant trends in: never events, significant incidents, themes in incidents, mortality, or unexpected deaths? What is the service doing to prevent future deaths as a result of incidents and mortality reviews? (including LeDeR)
  • Are there any significant trends where groups of patients are doing worse in terms of safety concerns?
  • Does the service report all deaths of people with a learning disability to LeDeR and does the service participate in LeDeR reviews?



E1: Are people's needs assessed and care and treatment delivered in line with current legislation, standards and evidence-based guidance to achieve effective outcomes?
  • How is the service identifying, cascading and keeping up to date with changes in clinical guidance?
  • Where people are subject to the Mental Health Act, how is the service ensuring compliance with the Act?
  • Have there been any deaths (COVID or non-COVID) in the service? Was full and timely access to primary and acute healthcare treatment in place before the patient’s death?
  • Where required, what are the arrangements to ensure access to appropriate end of life care and support?
  • How does the service ensure staff are able to identify the deteriorating physical health of patients who may not be able to communicate their needs?
E2: How are people’s care and treatment outcomes monitored and how do they compare with other similar services?
  • How is the service collecting information about people's care, treatment and outcomes? Where relevant, is the service continuing to submit to relevant national clinical audits?
  • How are outcomes being monitored for groups of people that may be at higher risk, such as different ethnic groups and older people?
E3: How does the service make sure that staff have the skills, knowledge and experience to deliver effective care, support and treatment?
  • How is the service ensuring that all staff, including those being flexibly re-deployed, have the skills and training to carry out their roles effectively?
  • Is the service providing regular supervision to staff?
  • Are staff provided with support and debriefing following incidents?
  • Do staff have training in how to support communication with people with learning disability or autistic people?
E4: How well do staff, teams and services work together within and across organisations to deliver effective care and treatment?
  • How is the service ensuring that the necessary staff, teams and services are involved in assessing, planning and delivering people’s care and treatment?
  • Does the service have effective discharge planning in place?
  • Does the service work proactively with commissioners to ensure that patients are discharged to services that meet their individually assessed needs and that they do not remain in hospital longer than is necessary for assessment and treatment?
E6: Is consent to care and treatment always sought in line with legislation and guidance?
  • How does the service ensure consent to care and treatment is always sought in line with legislation and guidance? Including, where appropriate:
    • ensuring that people are involved in decisions about not providing care and treatment, including advanced care plans and DNACPR decisions?
    • promoting supportive practice that avoids the need for physical restraint? Where physical restraint may be necessary, how does the service ensure that it is used in a safe, proportionate, and monitored way as part of a wider person-centred support plan?
    • ensuring staff apply relevant legislation where people may lack capacity to consent to particular care and treatment, including the Mental Capacity Act 2005 (including DoLS) and the Children’s Acts 1989 and 2004?


C1: How does the service ensure that people are treated with kindness, respect and compassion, and that they are given emotional support when needed?
  • How has the service adapted how it supports and engages with patients and their families/loved ones?
  • How does the service ensure that it delivers care that is compassionate and upholds people's human rights?
C2: How does the service support people to express their views and be actively involved in making decisions about their care, support, and treatment as far as possible?
  • How does the service support people to express their views and be actively involved in making decisions about their care, support and treatment?
  • Where appropriate, how is the service managing the impact of limited visiting on patients’ wellbeing?
  • How is the service promoting advocacy support and ensuring that patients know how to access it?
  • How does the service involve family and carers in people’s care, support, and treatment?
  • How has the service continued to support regular contact between patients, their family and friends?
  • Is WIFI good enough to enable relatives to keep in contact?


R1: How do people receive personalised care that is responsive to their needs?
  • How does the service ensure that it meets the needs of the population served and does it enable flexibility, choice and continuity of care?
  • Where relevant, do individual patients have choices about how, when and where they are seen?
R2: Do services take account of the particular needs and choices of different people?
  • How are services delivered, made accessible and coordinated to take account of the needs of different people, including those with protected characteristics under the Equality Act and those in vulnerable circumstances? This may include:
    • ensuring that each patient’s information and communication needs are identified, recorded, flagged, shared and met
    • identifying and making other reasonable adjustments for disabled people
    • Where new protocols for admission are being used, how are these being communicated to staff and how are they reviewed to ensure they are non-discriminatory?
    • How is the service supporting people to follow their interests and take part in activities that are socially and culturally relevant and appropriate to them, including in the wider community and, where appropriate, to have access to education and work opportunities?
R3: Can people access care and treatment in a timely way?
  • How is the service managing people's access to the service to ensure that high-risk patients/pathways are being identified and prioritised appropriately, including re-instating services and handling backlogs of activity?
  • Is there a structured approach to patient flow that ensures all components of the system are appreciated and managed appropriately, and flow issues are escalated appropriately? How does the approach take account of the pandemic?


W1: Is there leadership capacity and capability to deliver high-quality, sustainable care?
  • Has there been any impact on leadership capacity as a result of the COVID-19 crisis? Are there plans and mitigations in place if it is affected?
  • Do leaders understand the challenges to quality and sustainability during this period, and can they identify the actions needed to address them?
W3: Is there a culture of high-quality, sustainable care?
  • Is the service monitoring and protecting the health, safety and wellbeing of staff?
  • How is the service taking action to monitor and protect the health, safety and wellbeing of staff? For example, access to emotional support, supporting staff to raise concerns, adequately risk-assessing and placing staff in appropriate environments to protect their health and safety, including staff in different ethnic groups and other staff at high risk of COVID-19.
  • How does the service ensure a culture that encourages openness and honesty at all levels within the organisation, including with people who use services, in response to incidents? How does the service ensure that leaders and staff understand the importance of enabling staff to raise concerns without fear of retribution, and is appropriate learning and action taken as a result of concerns raised?
  • During the pandemic, there have been changes to the roles of commissioners and many have moved to frontline services; how have you become aware of, and adapted to these changes and the changes of personnel?
W4: Are there clear responsibilities, roles and systems of accountability to support good governance and management?
  • Is the service able to work effectively with system partners when care and treatment is being commissioned, shared or transferred?
  • Are there robust arrangements to make sure that hospital managers discharge their specific powers and duties according to the provisions of the Mental Health Act 1983?
W5: Are there clear and effective processes for managing risks, issues and performance?
  • Does the service have effective systems and methods for monitoring the overall quality of the service and for responding to business risks and issues as they arise? How often are these reviewed?
  • Are there robust arrangements for identifying, recording, and managing risks, issues, and mitigating actions? Is there alignment between the recorded risks and what staff say is ‘on their worry list’?