Care England Briefing: Registering the Right Support (RRS)

1.       Summary

RRS is CQC’s policy on handling new applications for registration and applications to vary registration for services supporting those with learning disabilities and/or autism.

CQC have adopted a ‘one size fits all’ approach when refusing to register new services which have more than 6 beds or vary registration for services to increase the number of beds to more than 6. Whilst CQC say this is not the only consideration, this is the experience reported by our members.

CQC’s concern with bed numbers is further characterised by its inconsistent approach to rating larger services as ‘Outstanding.’ Care England members indicate that services with more than 6 beds are unlikely to receive an ‘Outstanding’ rating from CQC. However, some larger services are able to achieve an ‘Outstanding’ rating. This highlights the lack of uniformity and consistency in CQC’s approach to service ratings.

RRS guidance is not being applied with a focus on the core principles set out in the national guidance on quality, and choice, but instead focusing only on one criteria, size. This is subsequently fuelling the problem of vulnerable people having to remain in hospital, an inappropriate and expensive environment, as community facilities are not being developed for fear of the investment in these new services being wasted as the services are then not registered by CQC. This is a particularly pertinent issue in light of the growing demand for social care services.

Recent NICE guidance on service design and delivery for people with a learning disability and complex needs (NG93) makes it clear that there is no persuasive evidence which justifies decisions based on any of the criteria NICE looked at to determine what drove quality in the provision of such care.

2.       Introduction

In response to the failures of care at Winterbourne View, the Department of Health and Social Care published its national service model ‘Transforming Care’ in 2012 which sought to reduce the number of people with learning disabilities and/or autism inappropriately placed in a hospital setting and increase the number of those in a community setting.

This national model has been built on by subsequent policy including: ‘Building the Right Support’ and ‘Building the Right Home’.

Despite such efforts, there remains a significant number of people with learning disabilities and/or autism who continue to be inappropriately placed and held in hospital settings.[1]

Under the NHS Long Term plan additional funding has been secured to continue the Transforming Care programme with the new goal of halving inpatient provision by 2023-24. If this ambition is to be realised, a greater understanding of the barriers which impede its success is needed.

3.       The issues

The RRS guidance states that CQC does not adopt a ‘one-size fits all approach’ in respect of applications to register a new learning disability and/or autism service or applications to vary registration.

However, Care England finds that CQC have adopted a blanket approach of refusing to register services which have more than 6 beds.

CQC have rebutted applications for registration or applications to vary registration from Care England members on the basis that their service is not compliant with the principles of RRS, despite such services being able to demonstrate compliance with all of the relevant principles. 

Although it is generally agreed that large services are unable to satisfy the nine core principles laid out in the national service model, the narrow interpretation of the RRS guidance focusing on bed numbers is to the detriment of choice, a person-centred ethos, community engagement and access to well-trained staff.

CQC’s concern with bed numbers is further characterised by their disinclination to rate services with more than 6 beds as ‘Outstanding.’ Yet, some larger services are able to achieve an ‘Outstanding’ rating which highlights the lack of consistency in CQC’s approach to service ratings.

Such a fixed position not only flies in the face of the evidence produced by NICE and professional judgement, but is to the detriment of those in need of care: evidence suggests that care in institutional settings is rarely person-centred and hospital placements are likely to be far from people’s families, friends and communities.

CQC’s position is also to the detriment of the wider economy: community beds are currently in scarce supply; local communities are not allowed to benefit from the creation of jobs in adult social care- the adult social care sector employs around 1.5 million people in England, making the adult social care workforce of equal size to the NHS.

On 31st January CQC released new guidance which concerns the revision of the RRS policy, which has been shared for input as part of a consultation. This new guidance followed a letter to Care England dated 27th January that said a rewritten document would not be available until March and did not say if it would be subject to a consultation. The new guidance issued by CQC has come in light of pressure applied by Care England who have held CQC to account over RRS. Although the new publication acknowledges that registration decisions should be ground in the 9 core principles of the national service model, a review is not action.


[1] NHS Digital reported that in October 2019 there remained 2,220 people located in a hospital setting, with 1,275 (57%) having a total length of stay of over 2 years.