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Right support, right care, right culture – CQC guidance for autism and learning disability

On 8 October 2020 the Care Quality Commission (the ‘CQC’) published the revised ‘Registering the Right Support’ guidance which is now called Right support, right care, right culture. This continues to be statutory guidance issued in accordance with s.23 of the Health and Social Care Act 2008.

The 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 the regulatory approach for these services, including registration
  • makes expectations clear to future and existing providers in terms of inspection, monitor and enforcement functions

The guidance has a greater focus on outcomes for people using the services. It outlines three key factors that CQC expects providers to consider if they are, or want to care for autistic people and/or people with a learning disability:

  • Right support

The model of care and setting should maximise people’s choice, control and independence

  • Right care

Care should be person-centred and promote people’s dignity, privacy and human rights

  • Right culture

The ethos, values, attitudes and behaviours of leaders and care staff should ensure people using services lead confident, inclusive and empowered lives.

How can providers demonstrate they are meeting the requirements?

Providers of new and existing services must demonstrate how they will meet:

  • the CQC’s characteristics of ratings for good in healthcare and adult social care
  • the fundamental standards
  • people’s expectations, as set out in the service model. People expect providers to comply with building the right support and the accompanying service model when designing or running a service.
  • the requirements in the guidance to demonstrate that:
    1. There is a clear need for the service and it has been agreed by commissioners. The service should be for local people to meet a local need and should not be intended to admit people outside of the local area.
    2. The size, setting and design of the service meet people’s expectations and align with current best practice. People who use services, and their families and representatives, should be involved in the design of the service. The guidance maintains that premises should not be developed as new campus or congregates setting and that the environment should not feel ‘institutional’. Sensory needs and preferences are to be taken into account.
    3. People have access to the community.
    4. The model of care, policies and procedures are in line with current best practice.

The CQC will continue to use this guidance in their assessments and judgements and urge providers to discuss any proposals or development ideas with the CQC directly before submitting an application and or making changes to services.

Has there been any movement in relation to the 6 bed rule?

The guidance is clear that the size, scale (number of beds) and design of the premises must not compromise the quality of care, people’s safety or their human rights. Many providers have been frustrated for some time by the CQC’s seemingly arbitrary reliance on six as the magic maximum number of people who use the service. The CQC have confirmed that they have never applied a six-bed limit in their registration or inspection assessments and will continue to register based on care that is person-centred, and promotes choice, inclusion, control and independence. The CQC explain that the guidance has always been set alongside other standards and 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)”. It is recognised that commissioners and providers will need to develop bespoke services particularly for those currently in the hospital system.

As can be seen in the case studies at Appendix A, the CQC have registered services with more than six beds as providers were able to demonstrate how care would be high quality and person-centred. The CQC have also confirmed that they have previously refused to register services that are smaller than six beds because providers could not offer sufficient reassurance that they could deliver person-centred care in line with current best practice.

As providers may be aware, there is scope to appeal the CQC’s registration decision to the First-tier Tribunal and may be interested to read the Tribunal’s comments in respect of those cases which can be accessed via judiciary.net. Some of these comments are also reported within the case study section of the guidance.

Comment

As touched upon in an earlier briefing regarding possible amendments to the Mental Health Act, a key difficulty is that the needs of the individuals intended to be served by this guidance is extremely broad. Whilst it is not intended to be a ‘one size fits all’, query whether this one could have been more helpful in recognising and making allowances for the variation in need. It has been commented by Professor Martin Green, Chief Executive of Care England that despite being reworked the policy has not changed and has reiterated that care providers need to know that decisions made around the regulation of their services are evidence-based. Providers may recall that concerns regarding how the policy was being applied were raised earlier this year in respect of the draft.

It may of course be that a wealth of further evidence has been collated and will be shared as part of the CQC’s ongoing review into restraint, seclusion and segregation. This remains to be seen as publication of the final report has been delayed due to an inability to engage with stakeholders effectively during the pandemic.


Disclaimer

This briefing is for guidance purposes only. RadcliffesLeBrasseur LLP accepts no responsibility or liability whatsoever for any action taken or not taken in relation to this note and recommends that appropriate legal advice be taken having regard to a client's own particular circumstances.

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