Identifying and responding to closed cultures

1 Identifying and responding to closed culturesGuidance for CQC ..1..2. What are the risk factors of developing a closed culture ?..4 3. What are the warning signs of a closed culture ?7 4. What is the potential impact of closed cultures on human rights and equality?.. 11 5. How can we identify a closed culture ?14 6. What action should we take where there are concerns?1831. IntroductionThe abuse at Whorlton Hall, Winterbourne View, Mid Staffordshire Hospital and other services highlighted the abuse and other breaches of human rights that result from closed cultures and the impact that these had on people . Amanda s story below illustrates what it is like to feel powerless within a closed culture in a mental health setting.

2 However, her story could take place in any health or social care setting where there is a closed culture , and people feel either too scared to voice their concerns or unable to make their voice heard. Amanda s story When I was a patient in a closed culture on a psychiatric ward, I felt completely vulnerable. The staff had all the power and I felt that whatever I did or said I was completely powerless. Some of the senior staff were so arrogant that they controlled everything. I could tell that some of the more junior staff disagreed with what was happening, but even they didn t feel able to speak up for the patients rights (and presumably for their own working environment too).

3 Even when I did try to say that things weren t safe, I was ignored. It felt like all my experiences, past education, training and work counted for nothing because I was the one who was mentally ill and they were the professionals . I may have been unwell, but I still knew that what was happening was wrong and was rejected when I tried to articulate this to the powers in the organisation. This happened to me as someone who is articulate and confident to speak up. We now need to stand up for those people who are in similar situations but are unable to make their voices the COVID-19 pandemic, there is an increased likelihood that inherent risk factors and warning signs will be present in more services.

4 This is because more services are effectively operating as closed environments with a reduction in external oversight and with potential staffing and leadership challenges. As a result, we must identify where closed environments might develop into closed of this guidance This guidance and its associated training will support operational staff to: understand what a closed culture is identify a closed culture understand what potential breaches of our fundamental standards involving human rights look like be alert to signs of breaches of our fundamental standards in services with a closed culture know the right questions to ask at the right time ensure the voices of people who use services are sought, listened to and acted on determine next steps if evidence is uncovered that suggests people are at risk of harm or have experienced harm or What are the risk factors of developing a closed culture ?

5 By a closed culture we mean a poor culture that can lead to harm, which can include human rights breaches such as abuse. Any service that delivers care can have a closed culture , and features of a closed culture include: staff and/or management no longer seeing people using the service as people very few people being able to speak up for themselves. This could be because of a lack of communication skills, a lack of support to speak up, or fear of abuse. this may mean that people who use the service are more likely to be at risk of harm this harm can be deliberate or unintentional. It can include abuse, human rights breaches or clinical harm. From our experience of regulating services, the likelihood that a service might develop a closed culture is higher if one or more of the four inherent risk factors described in the table below is present.

6 Section 3 gives guidance on the warning signs that a closed culture may present. Table 1 - Inherent risk factorsInherent risk factorSigns that risks may be higher in a particular servicePeople may be experiencingpoor care people are highly dependent on staff for theirbasic needs. people are less able to speak up for themselves without good support from the service, for example, in learning disability or children s services or care homes for people with dementia. Restrictive practices are used. In healthcare, people stay in a service for months or leadership andmanagement There are regular changes in management or managers are not regularly present and at times the service may run without a manager.

7 This may be more likely during COVID-19 due to staff being off sick or self-isolating. Managers are frequently absent from the service if they are responsible for two or more sites/ teams as a result, they are rarely present to challenge poor practice or promote good practice. The workforce comprises many members of staff who are either related or friends, causing cliques to risk factorSigns that risks may be higher in a particular service There is a lack of openness and transparency between managers, staff, people using the service and external professionals and organisations. Managers do not lead by example. Staff are not supported or encouraged to raise concerns.

8 Managers fail to monitor, and address issues raised by staff, people using the service, relatives and visitors to the service. Managers fail to respond to recommendations of others, for example professionals, commissioners and regulators. There are differing views between the multidisciplinary team or managers and care staff about how people are being skills, experience and training of staff providing care There is a high turnover of staff. There are consistent staff shortages. There is a high use of agency staff who do not know the people they are caring for (in mental health hospitals or residential care). There is a lack of suitable induction, training, monitoring and supervision of staff.

9 During COVID-19, employment checks are not as thorough (giving job applicants who could harm people who use services greater opportunities to be employed). Shift patterns within the service mean that the same people are always working together, and staff are not mixing with other colleagues. Staff work excessively long hours or of external oversight The service is in an isolated location resulting in people using the service having limited access to community services and facilities and less opportunities for friends and family to visit. There is a lack of monitoring by outside agencies. There is limited interaction with outside agencies due to failings on the part of the service to 6 Inherent risk factorSigns that risks may be higher in a particular servicesubmit mandatory information such as notifications or safeguarding referrals.

10 There are few visitors. During COVID-19 there are restrictions on access to, and less external oversight of all services by family, friends, social workers, visiting health care professionals, commissioners and What are the warning signs of a closed culture ?We always need to monitor services with inherent risks of a closed culture more closely than those without. However, we need to be alert to warning signs of a closed culture in all services. Unlike the inherent risk factors that indicate that a closed culture is more likely, warning signs suggest that a closed culture is developing or has already developed in a service. Warning signs can also be present in services with a low inherent risk of a closed culture , as a closed culture can develop in any service.