Services for autistic people and people with a learning disability

Right support, right care, right culture

How CQC regulates providers that support autistic people and people with a learning disability

Download an easy read version of this guidance

Registering the right support was published following consultation in 2017. From time to time we revise the guidance we issue. This guidance has been revised and retitled and continues to be statutory guidance in accordance with s.23 of the Health and Social Care Act 2008. 

Our policy on regulating providers that support autistic people and people with a learning disability remains unchanged from Registering the right support, but, having sought feedback, we have aimed to clarify to providers how we implement the policy in this update. 

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

We expect all providers, existing and future, to understand our regulatory approach. They must be aware of how we embed human rights in this and the requirements this places on them.

Our position on the size of residential services

When registering and assessing providers, our main concern is the quality of life that people experience and the care they receive.

This guidance refers to standards set by other organisations. This includes NICE guidance (CG142), which provides a definition of 'small' services for autistic people with a mental health condition and/or who are communicating a need, expressing their feelings or an emotional reaction. 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 autistic people, people with a mental health condition, or a learning disability supports this. For people currently in the hospital system, this is likely to require commissioners and providers to develop bespoke services.

NICE guidance NG93 includes the following recommendations for local authorities, commissioners and service providers when working with people with a learning disability who are communicating a need, expressing their feelings or an emotional reaction:

• Offer people 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.

Note: We continue to refer to NICE guidance in describing what 'small' means but this does not mean there is an absolute upper limit for the size of services. CQC has never applied a 6-bed limit when registering and assessing providers.

How we assess applications to register new providers or vary registration

We will only register providers if they can demonstrate that their services will maintain people's dignity and privacy and facilitate person-centred care. This must be in line with current best practice guidance and not be developed as new campus or congregate settings.

This applies to services with fewer than 6 beds as well as services with more than 6 beds. We will consider the size and design of residential settings as part of our assessments, alongside other considerations.

In our experience of registering and inspecting these types of service, we have found that providers of larger services will need to work to clearly demonstrate that they deliver high-quality, person-centred care. This guidance sets out in detail what that person-centred care needs to look like. It is unlikely that we will register services that are not provided in a similar way to ordinary residential accommodation.

We encourage you to use our pre-application process to discuss your ideas with us before applying to register a new service or to vary an existing registration if you intend to provide services for autistic people and people with a learning disability.

How we assess existing services developed as campus or congregate settings

We follow this guidance in our assessments and judgements to promote consistency, but we will always base each assessment on the evidence presented in that case.

We recognise that some services were developed and registered before we first published this guidance (or the preceding guidance ‘Registering the right support’). In those specific cases, the campus or congregate nature of the setting will not limit the rating we will award. In reaching our judgements, we will consider whether people are receiving safe, high-quality care that promotes their dignity, privacy and human rights, and that maximises their choice, independence and control.

However, we expect all providers to have clear plans to develop their services in line with good practice, as described in our guidance.

Purpose of this guidance

This guidance is statutory guidance in accordance with s.23 of the Health and Social Care Act 2008.

This 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 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.