Talk Health and Care

Registering The Right Support

Registering the Right Support was published in June 2017 by CQC. Within the Scope and Purpose of the document, it is referred to as a ‘policy statement’. Having spoken to several colleagues, there appears to be a consensus that as the regulator, CQC is intended to act in that capacity, but not as a ‘policy maker’. Through the document the content refers to both ‘guidance’ and ‘policy’, therefore it was unclear at the point of publication how this would be interpreted and therefore implemented.


Whilst I am sure all providers would like to ensure that Winterbourne View is never repeated and therefore welcome changes that will reduce the risk of any harm to someone with a learning disability (or any other individual), there are many factors to consider in relation to how this will be achieved. The primary focus of Registering the Right Support relates to the size, location and type of services being offered. All well and good, but the ‘guidance’ element of the document remains very unclear and refers to CQC adopting ‘the presumption of small services, usually accommodating six or less’. However, then goes on to say that ‘we will not adopt six as a rigid rule for providers of any service for people with a learning disability and / or autism’, providing that providers ‘are able to demonstrate that they follow all of the principals and values in Building the Right Support’ guidance.


Having consulted with a number of other providers and commissioners, the more recent rigid implementation of Registering the Right Support which has been reported is rather disconcerting because of the lack of clarity regarding what services might be registered and which might not. During conversations with a number of providers who have recently had registrations rejected, it has highlighted the major concerns for all organisations looking to invest in developing new services for people with learning disabilities and / or autism. The business risks associated with any substantial investments of any type over more recent years have been significant, but the ambiguity that is currently being created by the manner in which Registering the Right Support is being interpreted and implemented is of great concern to all.


It takes a significant length of time and capital investment from first conceiving a plan to develop a new service to the point of registration, meaning many businesses have recently had registrations rejected for businesses that were planned ahead of the June 2017 publication. I have felt fortunate that I learned of the ill fate of several proposed developments, literally days ahead of signing off the construction of a brand new 11 bedded service. As a result of the conversations held with providers and commissioners, we have felt it necessary to reduce the business risk of the project by reducing the number of beds within the plans.


Whilst not ideal, the decision to do so might have saved the business something in the region of £500K (minus those costs already laid out for planning and design). Others have not been so fortunate!


Again, closer regulation of providers for services for people with learning disabilities and / or autism to minimise the risk of harm to individuals is welcomed. However, where the regulator implements a policy that will potentially reduce the number of providers investing in delivering the necessary placements to support people back into community settings from long stay hospitals, this could adversely affect the national Transforming Care policy.


There is a contradiction with the approach behind the thinking within Registering the Right Support, which assumes that large services within rural settings are not appropriate for people with learning disabilities and / or autism: there are several ‘Outstanding’ services (as regulated by CQC) for people with very complex needs which are facilitating fantastic outcomes for individuals. How then can CQC deem these services as not being appropriate for people with learning disabilities, when by their own judgement they are rating them as ‘Outstanding’, with very many more being rated as ‘Good’?


Further, why is it OK to accept that for ‘older adults’ services, there are economies of scale, which means it is acceptable to have large institutional settings registered by CQC in rural locations for this client group. Surely, the extent of abuse within older adult settings has been documented and reported upon as equally as within younger adult settings, or at least it would be naïve to think that the risks are any less within these settings?


Given the apparent discrimination being shown towards ‘Good’ or ‘Outstanding’ providers of residential services to people with learning disabilities and / or autism, surely there is a call for CQC to review their approach to ‘Registering the Right Support’, so that people are in fact able to receive the right support?

edited on Nov 30, 2018 by Adam DHSC

Adam DHSC 5 months ago

Moderation status changed: Removed

Not on topic, political and not written from a person

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Adam DHSC 5 months ago

Moderation status changed: Clear

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Adam DHSC 5 months ago

Thanks for you comments. I wonder if you'd be able to comment on how this has an impact with the workforce?


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The Outstanding Society 5 months ago

There has been no direct impact on the current workforce in my organisation as there were no staff members recruited for this residential service at the stage of altering the building plans. However, given the wider context of this issue, there are implications to businesses which I have stated in terms of economies of scale; meaning that for some providers, to build a property to accommodate six or less people with complex behavioural needs would not be financially viable. The relative cost of building specialist and robust accommodation is very high and therefore a lower number of people living within a residential home will invariably mean that the income generated is going to take much longer to repay, leaving the business proposition in question with funding partners.

Granted, the overheads are going to be much greater in a larger residential service; the greatest of these costs of course, being staff costs and associated management costs to effectively run a larger service. However, having been responsible for both smaller and larger residential services for many years, I have observed first hand that the most effective services have been those that are very well managed. Of those that are very well managed, the outcomes for people with complex needs have been equally positive for those living in larger services as for those in smaller services. The greatest advantage of excellent environmental design in a larger setting, is that there are larger numbers of staff available to help support a complex client group, as well as each other when there are the inevitable difficult periods that occur in settings supporting people with complex behaviour.

Well trained, experienced staff members are human beings too and whilst I have led very effective residential services, I have also witnessed the impact that people with complex behavioural needs have on even the most professional of support workers. It is therefore the management team and other professional colleagues who provide the support to those staff members and enable them to continue in their professional roles, thereby maintaining staff retention levels. It is quite obvious that good quality, effective residential services have lower levels of staff turnover and this is in part to do with a sense of effective team working. In my experience, in settings where there are lower numbers of people being supported with complex behavioural needs, there are lower numbers of staff to provide the necessary support to each other and therefore there is a tendency to see greater turnover levels in smaller residential services where people supported are presenting higher levels of challenging behaviour. I would also argue that in a well led residential service, there is also a greater visibility and greater transparency of any staff practices that would be deemed to be inappropriate in a larger setting, due to higher numbers of effectively trained and experienced staff prepared to ‘whistleblow’.

I would agree that a larger staff team is harder to manage, but this depends on the effectiveness of the registered manager and the management structure supporting him or her in their role. I would argue therefore, that the size of a residential service is not the determining factor in maintaining the safety of the individuals receiving support, or the effectiveness of this, but that the leadership and effectiveness of the staff team(s) is the primary reason which dictates positive outcomes of vulnerable people being supported.

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Sam P DHSC 3 months ago

Thank you very much for posting your idea. Registering the Right Support is both policy and guidance; issued under the powers conferred on CQC by the Health and Social Care Act 2008.

There is no hard and fast rule about the size of services that CQC will or will not support. Where there has been focus on size and scale as part of an individual registration application, it’s because the principle of small scale settings is a factor that influences quality. The more people living together in a setting, the more potential barriers to choice and control. Size and scale is considered alongside other factors such as location, where people are from, links with local community, access to specialist support, distance from family and friends and available activities and community integration. CQC approaches each application on its own merits and doesn’t adopt a ‘one size fits all’ mentality.

CQC has given a commitment to discuss proposals for new developments at an early stage with providers in order to provide clarity. As CQC is in a period of transition from old to new models of care, it is inevitable that some older services will retain ratings based on an old model. Inspection of existing services which provide a traditional model focuses on “well led” and the provider’s intentions in transitioning their service towards a new model that fits with current best practice. CQC’s focus when considering applications for registration from new and existing providers, is always on ensuring it explores how the applicant has had regard for the principles of the guidance, how people will receive a good quality of life and a positive experience and ultimately, the impact of the applicant’s intentions and proposals, on the people using the service.

Registering the Right Support is CQC’s response to the national policy direction building on Valuing People: A New Strategy for Learning Disability; The Mansell report; and Building the Right Support. It was adopted following ‘Transforming care: A national response to Winterbourne View Hospital’ by the Department of Health and Social Care, and the Winterbourne View Concordat (to which CQC is a signatory). For any group of people, the system of care and support that surrounds that group will be unique. CQC will continue to offer its independent voice and participate with its partners and the wider sector in the ongoing national discussion on the quality of care for older people. Last year, it published “Beyond barriers: how older people move between health and care in England”, and in The State of Care 2017-2018, CQC highlights the particular challenges for older people when using health and social care services.

Thank you again for your idea, and please continue to share your thoughts on the #TalkHealthAndCare platform.


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