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The risks of a ‘closed culture’
In recent internal guidance, CQC inspectors have been told to operate a ‘low threshold for deciding to carry out a responsive inspection’ in homes that they consider to be at high inherent risk of having a closed culture. This means all providers must be ready for inspections to explore this area.
The guidance explains that, though perhaps most often found in learning disability and autism services, a closed culture can arise wherever ‘people may be less able to self-advocate, or are less likely to have their communication needs supported or to be listened to and believed than others.’ It gives examples:
- For CQC mental health teams: this includes mental health wards for children and young people, mental health rehabilitation wards and wards for people with an acquired brain injury or dementia.
- For adult social care services: this could include services for people with dementia, mental health conditions or acquired brain injury.
- For acute and community hospitals: this could include wards for people with dementia or frail older people that are essentially closed environments at night time.
Signs of a closed culture
The guidance highlights these warning signs that may mean a dangerously ‘closed’ environment or culture:
- concerns raised by staff working in the service, by families or others that relate to how people are being treated, incidents involving violence or how complaints are handled
- whether managers know what is happening in the service day-to-day
- whether managers acknowledge potential signs of poor culture or potential abuse
- a high proportion of people being cared for in some form of isolation, away from other people using the service
- people using the service being restricted without proper consideration of their human rights. As well as restraint, this includes restrictions on access to food and drink, to using the toilet, to going outside, to visitors and to their own clothes and possessions.
Relevant to all care settings
Many of the problems of very poor care that have led to CQC’s response happened in hospital settings, and particularly affect people with learning disabilities and autism. But many care homes fall into the ‘high risk’ group, whenever people lack capacity to make all of their own care decisions and are deprived of their liberty in their best interests. Dementia care is still too often provided in segregated, locked units, where a toxic culture can easily develop.
What can happen in a closed culture?
Every secretly filmed documentary, from the notorious Winterbourne View cruelty to last year’s exposé of taunting, bullying and hitting vulnerable people at Whorlton Hall private hospital, shows under-skilled, under-supervised staff dehumanising those they are supposed to care for. People are mocked or terrified, until they react by being angry or upset; they are then restrained, often held in solitary confinement, labelled as ‘acting out’ or ‘kicking off’, which leads to further restraint, including the use of medication. Typically, records are utterly misleading, picturing minimal restraint, with no explanation of why the person was upset.
How can we work with CQC to prevent the risks of closed cultures?
CQC wrote to providers in October 2019, and their letter https://www.cqc.org.uk/news/stories/new-supporting-information-inspectors-mental-health-act-reviewers-addresses-risk here explains:
Protecting people’s basic human rights is at the heart of good care. Everyone involved in the care of people in these services has a duty to act where there is a risk that a person’s human rights are being breached. We expect this of all our staff and of providers and all their staff.
We ask you to make sure that your services and staff are fully aware of what human rights are, and whether there is anyone in your care whose human rights are at risk of being breached. This could relate to the right to life, right to liberty, right not to be tortured or treated in an inhuman or degrading way, right to respect for private and family life, home and correspondence, and right to be free from discrimination.
We are currently reviewing our regulatory methodology and support for inspectors who look at services that have a high risk of a poor culture developing to see how we can strengthen our focus on human rights. Crucially, we will be focusing on placing a stronger weight on how we respond to the testimonies of people who use services, their families and staff working in services.
Three steps a manager can take
- Firstly, read the guidance. You can find it here
https://www.cqc.org.uk/news/stories/new-supporting-information-inspectors-mental-health-act-reviewers-addresses-risk. Share the summary with staff, explain why this new emphasis by CQC is to be welcomed rather than feared. Work out whether your service potentially falls into any of the risk categories, looking specially at people who might lack mental capacity for essential decisions.
- Secondly, highlight everyone at risk of having their human rights breached, for example due to communication difficulties, or where restrictions keep them safe. Encourage staff to find unique ways to support each individual to exercise their right to live life as they choose, wherever possible. Share examples of best person-centred practice in CQC inspection reports which have had ‘outstanding’ ratings for being well-led, effective and caring: ask staff to come up with their own ideas to enhance the happiness of individuals they know well.
- Thirdly, build into staff meetings ongoing reflection on the Mental Capacity Act, which protects the human rights of people who might lack mental capacity. Staff must, to meet CQC regulations, be familiar with the code of practice here https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/497253/Mental-capacity-act-code-of-practice.pdf .
Positive protection for human rights
The CQC has adopted the human rights-based FREDA principles here https://www.cqc.org.uk/sites/default/files/20190301_human-rights-approach_summary_largeprint_2.pdf. Do likewise, in supervision and team meetings. The initial letters of FREDA remind us all that our actions towards users of a service, or any decisions about them, must embody Fairness, Respect, Equality, Dignity, and Autonomy (which means giving people choice and control over their own lives wherever possible). It’s a welcome advance that CQC inspectors will be highlighting the risk of closed cultures to people’s rights. We all want people using our services to be happy, respected and fulfilled, rather than scared, bullied and intimidated. Embrace this development positively!
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