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Learning Disability and Autism services – recommendations for change

The CQC commissioned an independent review from Professor Glynis Murphy (Professor of Clinical Psychology and Disability) in June last year into how abuse exposed by the BBC Panorama programme in May 2019 could have been recognised earlier by the regulator. She was also asked to make recommendations for improvement.   Professor Murphy presented her report to the CQC at its public board meeting on 18 March 2020 which was held via video link due to Covid-19.The findings were published by CQC on the same day.

Her review highlights the challenges in providing services to people with learning disabilities and/or autism.

The recommendations and key points for providers in summary are as follows.

Recommendation 1:

CQC should consider displaying data, for each service, in a user-friendly way, on the following:

  • abuse allegations
  • complaints and concerns (coming into CQC via NCSC and other routes)
  • mandatory staff training
  • staff turnover
  • sickness rates
  • use of agency staff
  • restraints and segregations.

Data should be easy to access, chronological, and graphical, and allow inspectors and MHA reviewers to prepare and plan inspections, and to become aware of ‘red flags’ indicating failing services.

Key points for service providers:

Provision of data in this way aims to alleviate concerns about gaps in information. Service providers will need to be aware that statistics may be used to make assumptions about service provision and risk and that they may have to deal with these accordingly.

Recommendation 2:

For high risk settings which provide hospital services for people with learning disabilities and/or autism and complex needs, CQC should consider:

  • using only unannounced inspections, and
  • should include evening and weekend visits.

Alongside this:

  • CQC should require Provider Information on a regular basis, every 6 months (previously these were linked to up-coming inspections), so that PIRs do not signal imminent inspections.
  • all inspections should produce ratings, including focused inspections, and action plans by the provider should not be a sufficient reason for rating a service as ‘Good’ when it would otherwise be rated as RI.
  • inspection reports should be published more quickly (with a month to six weeks of the inspection) so that providers can improve services faster and inspectors can better plan re -inspections.

Key points for service providers:

Inspection methodology is likely to change and providers will have to adapt and respond quickly to the additional requirements. There has been much emphasis on the value of unannounced visits, especially at evenings and weekends to assist in detecting failings in a service.

Recommendation 3:

CQC should:

  • take abuse allegations, safeguarding alerts and whistleblowing events extremely seriously and recognise that they are probably the tip of the iceberg.
  • work closely with other agencies on these issues (LAs and CCGs) and should consider these data as a whole for services and examine their trends over time (rather than just seeing them as a series of individual cases).

Key points for service providers:

Detailed investigations are likely to follow repeated retracted allegations and in cases of escalation an increase in inspections and surveillance.

Recommendation 4:

In all inspections:

  • CQC should prioritise in-depth service user interviews, in private (i.e. without staff from the service that is being inspected), and
  • inspectors should receive training in alternative and augmentative communication tools such as Talking Mats.
  • CQC should also ensure that as many carers as possible are spoken to, about their views of the service, and
  • inspectors should spend more time observing in the lounges and day rooms to ensure they have seen the everyday nature of the service. There are a number of observation tools that could be used.

Key points for service providers:

Inspectors need to be appropriately trained to gather and assess views and experiences. The increased involvement of service users and their families is likely to give a range of opinion which will be helpful to providers when planning service provision. It will also be important for inspectors and providers to consider information in an unbiased and considered manner.

Recommendation 5:

Where the information about a service indicates that it is at risk of failing its service users (see Recommendation 1 and 3 above), for example, if it repeatedly has RI ratings or if its data on restraints or abuse allegations are at worrying levels, CQC should consider conducting a ‘level 2’ inspection.

Level 2 inspections should include:

  • more time in the service spent observing and interviewing service users, as well as staff surveys (to be returned to CQC, not to the provider), and
  • interviews with staff who left the service after only short periods.

CQC should also consider whether it is possible to rate the atmosphere and/or culture of services and should trial such a measure in inspections.

In addition, in a level 2 inspection, CQC should consider whether the importance of detecting abusive behaviour by staff, merits the use of CCTV or other covert surveillance.

Key points for service providers:

There is likely to be a more flexible inspection approach in appropriate cases and a balance will need to be struck between ethical considerations and a system which effectively safeguards human rights.

Recommendation 6:

CQC should not register services that are:

  • very isolated
  • in unsuitable buildings
  • with out-of-date models of care (difficult for families to access, high numbers of unqualified staff, poor provision of activities, low numbers of qualified nurses, and insufficient MDT presence).

They should not allow expansion of such services that already exist and should consider how best to alter those that they have already registered.

Key points for service providers:

Providers should work with the regulator to find appropriate ways to make alterations to services which are identified as unsuitable or outdated.


It was recognised by CQC that whilst there has been some work undertaken and supporting guidance has already gone to equip and support inspectors there was more to be done.

Kate Terroni gave an update at the board meeting as to what CQC have been doing since the Panorama programme and confirmed that Professor Murphy’s recommendations will “fold in” the lessons from the review and refresh the guidance. The guidance has been shared with Healthwatch and the Association of Directors of Adult Social Services.

There was reference to the independent review and report of David Noble published on 22 January 2020 and assurance was given that strategically there are a number of interlinking pieces of work ongoing and particularly around closed environments

Recommendations from both reports will be overseen by the Improving Regulation Today team.

Providers involved in services to people with learning disabilities and/or autism should anticipate developments and changes in the upcoming months and particularly in the approach to inspections.  Phase 2 of Professor Murphy’s review will be presented later in the year and this will include further improvements for CQC to consider.


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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