Guidance

Children’s homes and health care: registration with Ofsted or CQC

Updated 19 July 2024

Applies to England

Introduction 

This guidance clarifies registration with the Care Quality Commission (CQC) and the Office for Standards in Education, Children’s Services and Skills (Ofsted). 

In this guidance, we explain: 

• which regulator(s) you should apply to for registering a setting and/or activity 

• what registration means in practice 

Registration should always be in the best interests of children. Therefore, you should take a child-centred approach when considering your registration arrangements. You should make sure you understand the relevant legislative requirements.  

This guidance clarifies the registration arrangements for: 

• children’s settings where the main function is to provide care and accommodation but not to provide CQC regulated activities. These settings should be registered with Ofsted only 

• children’s homes that provide health care that falls within the scope of CQC regulated activities. These should be registered with both Ofsted (as a children’s home) and with CQC 

• CQC regulated activities that are delivered to children (mainly in hospitals), which should be registered with CQC only  

The guidance will help commissioners and providers to decide whether: 

• a children’s home that is registered with Ofsted is providing regulated activities that must also be registered with CQC 

• a provider registered with CQC also needs to register accommodation with Ofsted as a children’s home 

The guidance does not cover other forms of children’s services that may be regulated under the Health and Social Care Act 2008 (HSCA 2008), including homecare (domiciliary care) and independent hospitals and hospices. 

Ofsted regulates settings that provide children’s social care, whereas CQC regulates health and social care services (regulated activities) and not ‘settings’. 

We will review this guidance regularly to keep it up to date with new models of care in the sector. Ofsted and CQC are committed to working together to identify and act on any regulatory gaps between the 2 inspectorates.   

What Ofsted registers and regulates 

Ofsted is responsible under the Care Standards Act 2000 (CSA 2000) for regulating establishments and agencies that provide children’s social care services. These are referred to as ‘settings’ in this guidance. 

There are 7 types of setting that require registration with Ofsted: 

• children’s homes (including secure children’s homes) 

• independent fostering agencies 

• voluntary adoption agencies 

• adoption support agencies 

• residential family centres 

• residential holiday schemes for disabled children 

• supported accommodation 

Ofsted has a range of enforcement powers that it can use when a regulated service fails to meet the requirements of the CSA 2000 and the relevant regulations. 

Any person carrying on or managing a children’s home that provides care and accommodation must register with Ofsted in respect of that individual children’s home. Failure to do so is an offence under section 11 of the CSA 2000. 

What Ofsted inspects 

Ofsted inspects, but does not regulate, other types of children’s social care provision or services under the Education and Inspections Act 2006. These include secure training centres and the Children and Family Court Advisory and Support Service (Cafcass).  

Other responsibilities for Ofsted include: 

• since April 2007, inspecting local authority children’s services under section 136 of the Education and Inspections Act 2006 under various frameworks. The current framework is the inspection of local authority children’s services (ILACS). And since 2016, carrying out multi-agency inspections under section 20 of the Children Act 2004 in the form of joint targeted area inspections (JTAIs) 

• inspecting the welfare of children in residential special schools, some boarding schools, residential further education colleges and independent specialist colleges under section 87 of the Children Act 1989 

• inspecting schools, colleges, initial teacher training, work-based learning and skills training, adult and community learning, and education and training in young offender institutions 

What CQC regulates 

CQC is the independent regulator of health and social care in England. This includes most types of health care for children, as well as care homes and homecare (also called domiciliary care) agencies, some of which may provide services to children. 

Section 10 of the HSCA 2008 sets out the requirement to register as a service provider. This can be as an individual, a partnership or an organisation (for example, registered companies or charities, NHS trusts and local authorities). CQC registers providers carrying on regulated activities and, if applicable, their associated registered managers. It does not register service types or professions. To be registered, providers must meet the fundamental standards of quality and safety set out in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.  

You should read CQC’s scope of registration to understand whether you need to register with CQC and how to do this. 

Definitions  

To help you decide which regulator to register with, we have defined the meaning of several different terms: 

Children’s home: a setting that provides care and accommodation wholly or mainly to children as defined in Section1(2) the CSA 2000.  

Child: a person under the age of 18 as defined in section 121 of the CSA 2000. 

‘Wholly or mainly’: this means that most of the people who live or stay at a children’s home must be children. Young adults aged 18 and over who live or stay at the home must be in the minority. Likewise, children under 18 receiving healthcare activities in a care setting where they live, and the activity is regulated by CQC, must be in the minority. 

Residential special school: a setting that operates as a school but also provides residential accommodation to vulnerable children who attend that school, for example disabled children and those with special education needs. But this should be for no more than 295 days in any 1 calendar year. 

Residential special school also registered as a children’s home: a setting that operates as a school but provides residential accommodation for more than 295 days a year and has registered that residential accommodation as a children’s home.   

Residential family centre: a setting where accommodation is provided for children and their parents, and the parents’ capacity to respond to the children’s needs and to safeguard their welfare is monitored or assessed. 

Supported accommodation: a setting where looked after children and care leavers aged 16 or 17 live and receive support from staff who may or may not stay at the setting. The provider is registered with Ofsted to provide supported accommodation at several specified addresses. 

Supported living (sometimes referred to as supported housing): services that often provide personal care to adults as part of the support they need to live in their own homes. Supported living is not currently a regulated activity. The regulated activity of personal care is provided under separate contractual arrangements to those for the person’s accommodation and the provider of the personal care should be registered with CQC. The accommodation is often shared but can be a single household. Supported living providers that do not provide the regulated activity of personal care are not required by law to register with CQC.  

Hospice: an establishment for which the main purpose is to provide palliative care and end-of-life care. In the context of support for children, hospices often provide short-break specialist care for children who have life-limiting conditions but may not be at the stage of requiring palliative care. 

Domiciliary care (also called homecare): the range of services put in place to support a person in their own home. In the context of support for children, this might mean services provided to children in their family home, and the staff delivering or providing personal care are employed by an agency registered with CQC as a provider (domiciliary care agency). Note: if a provider is providing care and accommodation to children and the staff who deliver the care are employed by a provider registered with CQC, the provider must still register the home with Ofsted.  

Healthcare services: services provided by a healthcare professional or by any individual person working under the supervision of a healthcare professional. This covers both physical and mental health provision, and ranges from visits to the local hospital for treatment as an outpatient to the administration of medication or a procedure such as injecting insulin in a child who is diabetic. 

Regulated activity: Section (8.1) of the Health and Social Care Act 2008 describes this as ‘an activity involving or connected with the provision of health or social care’. In relation to children’s services, related regulated activities include treatment of disease, disorder or injury and personal care. See CQC’s Scope of registration and also the Health and Social Care Act (Regulated Activities) Regulations 2014 schedule 1 which contains the legal definitions of the regulated activities.  

Treatment of disease, disorder or injury (TDDI): this is a legally defined regulated activity as set out in the Health and Social Care Act (Regulated Activities) Regulations 2014 schedule 1. It describes the provision of treatment by or under the supervision of a defined list of healthcare professionals, or by a multi-disciplinary team for treatment of a disease, disorder or injury. 

Personal care: this is a legally defined regulated activity as set out in the Health and Social Care Act (Regulated Activities) Regulations 2014 schedule 1. It relates to physical assistance given to a person to help with tasks for daily life, for example eating or drinking, helping people use the toilet, including help with bathing and dressing, and prompting and supervising a person to do any of these activities, where the person is unable to decide for themselves about performing such an activity without being prompted or supervised. 

Prompting and supervision: where staff prompt and directly supervise a person when they are carrying out their personal care and where the person is unable to decide for themselves without being prompted. Supervision should include direct observation of the action as it is carried out or checking on how it is being carried out. It will not normally include merely encouraging someone to perform the activity or checking at some point afterwards whether it has been done. It can include supporting someone to develop their own self-care skills and supervising them to assess progress.  

Accommodation for persons who require nursing or personal care: this is a legally defined regulated activity as set out in the Health and Social Care Act (Regulated Activities) Regulations 2014 schedule 1. This is where residential accommodation is provided together with nursing care or personal care as a single package, for example nursing or personal care in a care home. It usually means that the person using the service cannot choose to receive personal care from another provider while they are living in the accommodation.  

Assessment or medical treatment for persons detained under the 1983 Act (Mental Health Act): this is a legally defined regulated activity as set out in the Health and Social Care Act (Regulated Activities) Regulations 2014 schedule 1. This regulated activity relates to the treatment of people who are detained in, or recalled to, hospital for assessment and/or medical treatment under the Mental Health Act 1983. This includes people whose initial detention was under another enactment, but which has taken effect as a Mental Health Act detention. See CQC’s guidance on Assessment or medical treatment for people detained under the Mental Health Act 1983.

NHS continuing healthcare: a fully funded package of care that some people are entitled to receive because of disability, accident or illness. It covers the full cost of a person’s care and residential accommodation. 

Special considerations (formerly service user bands): the range of people’s needs that the service intends to meet, and the age range those services are delivered to.   

Children’s homes or residential special schools that also provide healthcare services 

A provider will need to register with CQC if it delivers healthcare to children that is a CQC regulated activity, even if it is also registered either: 

• as a children’s home with Ofsted 

• as a residential special school (RSS) with the Department for Education (DfE) 

Some providers will therefore need to register settings with Ofsted as a children’s home, or with DfE as an RSS, as well as with CQC for the healthcare services they provide at that location under the HSCA 2008. 

Services offered by children’s homes or RSS that are likely to require registration with CQC as a regulated activity include: 

• accommodation for people who require nursing or personal care  

• accommodation for people who require treatment for substance misuse including therapeutic, psychological, medical or psychiatric treatment 

• surgical procedures performed by a medical practitioner 

• diagnostic and screening procedures 

• nursing care 

You do not need to register with CQC if any child is receiving regulated healthcare activities at the setting which are delivered by another provider. This may include receiving specialist health care support from, for example a GP, or specialist community nurse, which is delivered in the children’s home or RSS, as long as the person delivering the health care support is not employed directly by the provider. Where a person delivering the health care support is employed directly by the provider, then this regulated activity must be registered with CQC. 

Determining whether healthcare activities need to be registered under the HSCA 2008 

Most children’s homes provide some form of healthcare service. These can range from administering over-the-counter remedies or basic first aid, to high-level healthcare tasks that are classed as a regulated activity. The purpose of registration with CQC is to ensure that services providing regulated activities are regulated appropriately. This ensures that the regulated activity being delivered to children is safe and of a high quality. 

The legislation requires that the provision of treatment for a disease, disorder or injury must be registered with CQC where it is delivered either: 

• by, or under the supervision of, a healthcare professional or a team that includes a healthcare professional 

• by a social worker, or a team that includes a social worker, where the treatment is for a mental disorder  

Delegating regulated healthcare activities 

A healthcare professional employed by a provider registered with CQC for the regulated activity of treatment of disease, disorder or injury can delegate a procedure to a care worker or nursing associate who is employed by a second provider, such as a children’s home.  

The healthcare professional, for example a nurse employed by a community trust or an NHS hospital trust (first provider), must ensure that the task is appropriately delegated and must assess whether it is within the worker’s competence. The first provider remains responsible for the regulated activity. The second provider (the children’s home) is not, therefore, carrying on this regulated activity and is not required to register with CQC for it.  

As the healthcare professional will not be supervising the person to whom the task has been delegated on a day-to-day basis, it is the responsibility of the children’s home as a provider to ensure that it does not allow its staff to accept delegated tasks unless they have enough support, supervision, education and training to competently undertake the aspects of care being delegated. The children’s home provider is also responsible for ensuring that it has a process to enable this. 

Determining whether a healthcare service should be registered as a children’s home 

It is the provider’s responsibility to ensure that it is registered with the correct regulator(s).   

When a provider applies to register with both CQC and Ofsted, the regulators will coordinate their approach and agree the most appropriate registration sequencing.  

Each regulator will still need to follow its individual legal processes to register or refuse the applicant. 

Registration and oversight regimes for different settings 

A children’s home registered with Ofsted: 

• Ofsted will inspect the setting at least once a year. Ofsted can take necessary action against the provider to ensure that it maintains good practice and cares for children safely 

A children’s home registered with Ofsted with healthcare activities registered with CQC: 

• Ofsted will inspect the setting at least once a year and take necessary action against the provider to ensure that it maintains good practice and cares for children safely 

• CQC will assess and inspect the CQC regulated activity in the setting. The assessment will be either responsive (in response to information relating to concern) or planned. CQC does not always carry out a site visit during assessments. If children were not receiving the healthcare provision at the time of the assessment, then CQC would not inspect 

A care home where a child under 18 is living and their care is being provided by a domiciliary care agency: 

• CQC will assess and inspect the CQC regulated activity in the setting. The assessment will be either responsive (in response to information relating to concern) or planned. CQC does not always carry out a site visit during assessments. If children were not receiving the healthcare provision at the time of the assessment, then CQC would not inspect 

• The care home must be registered with Ofsted as a children’s home. Ofsted will inspect the provider at least once a year. Ofsted can take necessary action against the provider to ensure that it maintains good practice and cares for children safely 

A care home registered with CQC that can accommodate children and adults: 

• CQC will inspect the quality and safety of the care being provided to children, but only if the children were receiving regulated activity at the time of the inspection  

A hospice or hospital registered with CQC: 

• CCQ will assess and inspect the healthcare services either in response to risk or as a planned assessment 

Examples to help determine the appropriate regulator to register with 

Type of setting and services offered	Appropriate regulator
The primary service is care and accommodation for children, which meets the definition of a children’s home under the Care Standards Act 2000.	This setting must be registered with Ofsted. If the children receive healthcare services at the home (for example injections, or help from the diabetic or asthma nurse), unless the professionals are directly employed by the provider, the children’s home does not need to register these services with CQC. If the children are receiving healthcare services that have been delegated to care staff (see definitions), then the home does not have to register with CQC.
The primary service is accommodation for people who require nursing, or personal care for adults aged 18 and above only.	This setting must be registered with CQC. If the provider has informed CQC that children will be receiving care and accommodation at the location, but the service is wholly or mainly for adults, it only needs to register with CQC. These providers must have the correct special considerations (formerly service user bands) on their CQC registration to reflect this position. If the service then becomes wholly or mainly for children who are receiving regulated activity, then the home must also register with Ofsted as a children’s home.
Although children stay at the setting, the primary service is healthcare and it meets the definition of regulated activity, for example treatment of disease, disorder or injury usually delivered in a hospice or hospital.	This setting must be registered with CQC.
The primary service is residential care and accommodation for children aged under 18, but there are 1 or more regulated healthcare activities being delivered by a healthcare professional employed by the provider.	This setting must be registered with Ofsted as a children’s home as well as with CQC for the regulated healthcare activities.
The service is a hospital (as defined within the meaning of the National Health Service Act 2006) to which a child is admitted.	This setting must be registered with CQC.
The service provides support and accommodation for looked after children and care leavers aged 16 and 17.	The service must be registered with Ofsted, even if the regulated activity is provided by a homecare (domiciliary care) agency registered with CQC.

What if I still need further guidance?  

If you still need to clarify which regulator you should register with, you can contact either regulator: 

• CQC 

• Ofsted 

When necessary, they will discuss and agree options and advise you appropriately. In making this decision, the regulators will consider who provides the healthcare and who retains overall clinical responsibility. 

Further information 

Key reference documents for Ofsted include: 

• guide to registration for children’s social care services 

• changes to children’s social care services that are registered by Ofsted 

• Children’s Homes Regulations, including the quality standards: guide 

Key reference documents for CQC include: 

• scope of registration 

• guidance for providers on registration 

• regulations for service providers and managers  

The relevant Ofsted legislation includes: 

• The Care Standards Act 2000 (Registration)(England) Regulations 2010 

• Children’s Homes (England) Regulations 2015 

Legislation relevant to CQC’s functions is available in continuously updated versions. These include: 

• The Health and Social Care Act 2008 

• The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 

• The Care Quality Commission (Registration) Regulations 2009 

Also see the memorandum of understanding between Ofsted and CQC.  

Note: You must refer to the appropriate and up-to-date version of any legislation or guidance from these links.