The article below, ‘How to eliminate closed cultures?’ was first published in the latest issue of the Carer (Issue 57)
On the same day that the CQC published a new strategy, which at its very heart aims to tackle inequality and promote diversity and human rights, the Winterbourne View scandal made the news again. A decade after the BBC Panorama exposé, which uncovered a culture of systematic and systemic abuse, the BBC reported that the families of those who has been abused had written to the Prime Minister demanding change. Their views are shared by Mencap and the Challenging Behaviour Foundation, who say that over 2,000 people with autism and learning disabilities still reside in assessment and treatment units.
That the two announcements came on the same day was particularly ironic. Why? Well, one of the key themes of the CQC’s new strategy places a much greater emphasis on providers developing a strong safety culture within their services. Indeed, the overriding message from the CQC is for providers to embed a deep cultural fabric within their services that eliminates toxic environments that often lead to closed cultures.
Closed cultures: What are they?
So, what is a closed culture? I’m sure that I don’t have to tell you, but the definition is vague and ambiguous. It lacks detail and nuance. The CQC defines it as a “poor culture that can lead to harm, including human rights breaches such as abuse”.
A far greater challenge for providers and inspectors is to be able to identify close cultures. So, perhaps a better question to ask is, ‘what do closed cultures look like in practice as many care professionals may never have experienced one?
Having worked as a specialist in a number of different areas including Adults with Learning Disabilities and Complex Needs for many years, there is very little that I haven’t seen. But closed cultures are different. The minority of Managers that choose to embrace these closed environments, which sometimes operate in tiny pockets of a service, don’t want you to see them. They are masters of concealment and that’s why even the most experienced inspectors sometimes fail to spot these extremely damaging cultures until it’s too late.
Closed cultures: How to recognise them.
Being tutored by a director, who taught me the value of acting on instinct, has alerted me to tell-tale signs when a closed culture might be present. In my previous roles I have assessed service users in settings where a closed culture has been identified and can attest to the fact that gut reaction certainly plays its part. Services with closed cultures often put down roots when directors never come into the building, let alone spend time in areas frequented by service users. They sometimes establish themselves in services with set rotas, where teams are never mixed, which allows closed cliques to form.
Another red flag lies in the language that staff use. It tends to be unprofessional vocabulary that cheapens the notion of person-centred care and ultimately robs service users of their dignity. For example, they might use the word ‘softs’ when referring to service users who need to eat blended foods. They might term those living with dementia and certain Mental Health Conditions as ‘walkers.’ Or, they might use the phrase ‘double-up’ when a person requires support from two care workers. In a service where providers, directors, managers and senior staff don’t interact with staff teams and service users, they don’t see and hear this behaviour and so they cannot address it.
But how do providers respond to and eliminate closed cultures? In its new strategy the CQC has proposed a raft of ways to do so. Firstly, it is calling on providers to instil a safe culture. That means promoting a culture of openness, transparency and accountability. In short, it must be a culture which is instilled from the top, is built on the ‘Mum Test’, and one which allows front line staff to learn from their mistakes without living in fear for their jobs.
Content providers have an important role to play too
Most importantly, however, while leaders need to inculcate the culture, it must be a culture of shared responsibility. In other words, staff must be given the policies, the procedures, the best practice learning and the technology to feel that they can make difference. In this respect, QCS, the leading provider of content, guidance and standards for the social care sector, can add great value. By ensuring that staff have the right tools at the right time, it reinforces a culture of shared responsibility and helps to keep closed cultures at bay.
That is not to lessen the importance of carrying out targeted programme of inspections, however. Curiously the CQC’s new strategy is proposing the opposite. It wants fewer inspections to take place while placing a greater emphasis on gathering a wealth of information from a wider network of local services that co-produce with providers. While we must give the CQC some credit for this very innovative approach, I’m not sure that I agree with its decision to cut down on inspections. If the CQC is really serious about ridding the care sector of close cultures, it actually need to carry out more targeted inspections. It’s not enough to even conduct several inspections on different days. Inspectors need to have the confidence to inspect when they feel it necessary to do so.
Peer-to peer reviews a panacea
While co-production already plays a significant role in other areas of the new strategy, working more closely with Registered Managers from other services should be actively encouraged. I regularly hear positive stories from front line managers actively collaborating with their counterparts at nearby services. Many have gone on to form friendship and mentorship programmes, which enable peer-to-peer review to take place. Having different managers and care professionals mock-auditing different services is a great way to not only shine a spotlight on blind spots, but also to expose closed environments.
But I want to end this article on a positive note. As much as closed cultures continue to present a problem, we should never lose sight of the fact that they are present in a tiny minority of services. Yet they attract headlines and gain such prominence. As a sector, we should not be afraid to give ourselves a pat on the back every so often. We should occasionally celebrate the achievements of the many fantastic providers who achieve life changing success for those they care for. Their inspirational work may not make the newspapers but it profoundly changes lives for the better. It also shows that there is as much to learn – if not more – from the good then there is from the bad.
You can find the latest issue of the Carer (Issue 57) here