Right Support, Right Care, Right Culture: CQC Guidance Explained

Right Support, Right Care, Right Culture: CQC Guidance Explained

CQC’s statutory guidance for services supporting autistic people and people with a learning disability: the three factors, the four things you must demonstrate, campus and congregate settings, and the pre-application process.

Right Support, Right Care, Right Culture is CQC’s statutory guidance, issued under section 23 of the Health and Social Care Act 2008, that sets out what good care looks like for autistic people and people with a learning disability, and how CQC registers, assesses and rates the services that provide it. It replaced and retitled CQC’s earlier “Registering the right support” guidance, and CQC says its underlying policy has not changed. It applies alongside, not instead of, the standard key questions and quality statements, across residential care, supported living, specialist colleges and hospital settings.

If your service supports autistic people or people with a learning disability, CQC applies this guidance on top of its standard framework. This page follows CQC’s own guidance closely: the three factors, the four things CQC expects you to demonstrate when it registers or assesses a service, its position on campus and congregate settings and service size, and how to use its pre-application process. CQC’s guidance is statutory, so treat it as a primary source alongside the regulations.

What Is Right Support, Right Care, Right Culture?

CQC’s guidance says autistic people and people with a learning disability are entitled to an ordinary life, with the choices, dignity, independence and community access most people take for granted. The guidance sets out CQC’s regulatory approach for these services, covering registration, inspection, monitoring and enforcement, and CQC uses it in assessments and judgements to promote consistency, while basing each judgement on the evidence in that case (CQC: Services for autistic people and people with a learning disability). It applies to residential care, supported living, specialist colleges and hospital settings, for children, working-age adults and older people.

It is statutory guidance under section 23 of the Health and Social Care Act 2008. CQC says it was originally published as “Registering the right support” following a 2017 consultation, and has since been revised and retitled, with its underlying policy unchanged, to clarify how CQC implements it.

The Three Factors

CQC assesses all three together. Right support and right care can partly be checked against documents such as care plans and the physical environment. Right culture is harder to evidence with paperwork alone, because it is about whether staff attitudes and everyday practice genuinely deliver choice and independence when no one is specifically watching.

What CQC Expects You to Demonstrate

CQC’s guidance says people’s human rights, needs and preferences are at the heart of its registration decisions and inspection judgements, and that providers must comply with regulations and apply national policy and evidence-based guidance, particularly Building the right support and its accompanying service model. Providers must show four things (CQC: How providers can demonstrate they are meeting the requirements):

1. There is a clear need for the service, agreed by commissioners. CQC wants written evidence the service was requested by, or agreed with, local commissioning partnerships, supported by the Market Position Statement and underpinned by Joint Strategic Needs Statements, Joint Health and Wellbeing Strategies and Integrated Care Systems plans. It should serve local people, not admit people from outside the area. For hospitals, CQC wants NHS England’s written request for regional provision.
2. The size, setting and design meet people’s expectations and current best practice. People and their families should be involved in designing the service. CQC references NICE guidance NG93, NG11 and CG142, and says the size, scale and design must not compromise care quality, safety or human rights, must maintain dignity and privacy, must facilitate person-centred care, and must not be developed as a new campus or congregate setting. The service should be in or have good access to the local community, not secluded or geographically isolated, and should use co-production with the people it supports.
3. People have access to the community. People should be able to participate in their own local community, be registered with local health services, and access the same services and activities as anyone else in their chosen community.
4. The model of care, policies and procedures reflect current best practice. Approaches to behavioural needs should not be reactive or rely on restrictive practices or seclusion. Providers must understand the risk of closed cultures and have measures to prevent them developing, focus on people’s strengths, and show how Positive Behaviour Support informs practice. Supported living arrangements should meet the Reach Standards and the Real Tenancy Test.

CQC’s guidance adds specific expectations for Shared Lives schemes (maximising people’s control of their own lives, meaningful relationships and democratic rights) and specialist colleges (maximum choice and control, least restrictive support, and care that is not compromised by institutional practices).

Campus and Congregate Settings, and Service Size

CQC defines campuses as group homes clustered on the same site, usually sharing 24-hour staff and some facilities, and congregate settings as separate from communities and without the options, choices, dignity and independence most people take for granted. CQC says it will not register new campus or congregate settings, in line with current best practice.

On size, CQC refers to NICE guidance (CG142), which describes “small” residential services as usually no more than six people with well-supported single-person accommodation, and to its own review of restraint, prolonged seclusion and segregation, which supports that position. CQC is explicit, though, that it has never applied an absolute 6-bed limit when registering or assessing providers, and that this applies to services with fewer than 6 beds as well as more. What CQC actually assesses is whether the service can demonstrate it maintains dignity and privacy and facilitates person-centred care, in line with best practice, whatever its size. Larger services need to work harder to show they deliver that.

For existing services registered before this guidance (or its predecessor) that were developed as campus or congregate settings, CQC says the campus or congregate nature will not by itself limit the rating awarded. It will judge whether people receive safe, high-quality care that promotes dignity, privacy, human rights, choice, independence and control, while still expecting providers to have clear plans to develop the service in line with good practice.

Applying to Register or Vary a Service: Use the Pre-Application Process

CQC strongly encourages discussing plans before submitting an application, ideally early in planning and before investment decisions. Complete the pre-application questionnaire and email it to CQC; you will then be put in touch with a registration specialist for these services who arranges a discussion (CQC: Services for autistic people and people with a learning disability, before you apply). CQC is clear that this discussion can advise on the likelihood of registration, but only a full application and assessment can decide it. See how to register with CQC for the wider registration process.

Where the Guidance Comes From

CQC traces the policy back to the 2011 exposure of abuse at Winterbourne View hospital and the Department of Health’s Transforming Care response, followed by the Winterbourne View Concordat, which CQC signed. NHS England, ADASS and the LGA published Building the right support in October 2015 with an accompanying service model, and Building the right home in December 2016 on housing. The principles carried into the NHS Long Term Plan (2019), which committed to reducing inpatient numbers, increasing community support and improving inpatient care quality (CQC: Background and further reading). CQC positions itself as a partner in the Transforming Care Delivery Board.

Does This Apply to Your Service?

The guidance applies specifically to services that currently, or intend to, support autistic people and/or people with a learning disability, whether or not that is the whole of what you do. If even a subset of the people you support fall into this group, CQC assesses that part of your service against this guidance, alongside the standard framework for everyone else. CQC says it will always take appropriate regulatory action if people’s needs are not being met, or if a provider cannot show it delivers person-centred care that promotes choice, inclusion, control and independence.

What to Have Ready

• Commissioner agreement and needs evidence for the service, and Market Position Statement alignment.
• How the size, design and location were chosen, with people and families involved, and how it avoids a campus or congregate model.
• Evidence of community access: local health registration, activities and relationships.
• Restrictive practice records, tracked and reduced over time, not just a policy. See restrictive practice and restraint.
• Positive Behaviour Support training and evidence it shapes practice, including Oliver McGowan mandatory training.
• Supported living: evidence against the Reach Standards and the Real Tenancy Test.

Sources: CQC: Services for autistic people and people with a learning disability · CQC: How providers can demonstrate they are meeting the requirements · CQC: Background and further reading · CQC: Before you apply