Why a Closed Culture in Care is a Problem

We have put together this article about closed cultures to raise awareness, improve knowledge and protect those who need it. We’ve been assisted by colleagues who have decades of direct experience managing compliance in social care, in residential, domiciliary and supported living services. 

To answer your questions, we will be taking a closer look into a closed culture definition and examples, how to recognise and respond to a poor culture, and CQC guidance surrounding the subject. After reading this article and the additional material we have to offer you will be ready to prevent, detect and respond properly to the emergence of closed culture anywhere in your care service.

What is a Closed Culture?

Closed cultures in health and social care can increase the risk of harm to people in a care service, due to deliberate or unintentional abuse, negligence and breaches of human rights. Whether it was an accident or on purpose, a closed culture often results in unacceptable harm being bestowed on individuals.

For example, due to poor management, lack of staff or just pure laziness/carelessness, service users may be left unwashed for days or even weeks at a time. Or bathroom requests may be ignored. Some service users may end up relying on friends or family members to help them with basic care and even feeding during visits.

All care staff have a duty to protect people from abuse and avoidable harm. You should use this article to open up conversations about closed cultures in your care service and consider your opportunities to better understand the experiences of people using your service.

Examples of Closed Cultures

Unfortunately, closed cultures have entered the spotlight due to real-life cases getting out of hand. These cases are upsetting and could have been prevented, but at the same time, they have helped everyone in the care sector learn from other people’s mistakes which can reduce the risk of a poor culture developing in their business. The CQC is also taking the right steps to prevent these situations from repeating themselves in the future. 

• Examples of deliberate closed cultures - Winterbourne View and Whorlton Hall.
• Example of unintentional closed culture - Mid Staffordshire NHS Foundation Trust.

Recognising Closed Culture in Care

Some common warning signs could mean a care service is experiencing or at risk of developing a closed culture. These can be linked to leadership and management to the experience of past and present service users. Here are some key considerations to include when following the Risk Management framework:

• Leadership and management – You need to consider if senior staff know what’s happening and if they spend most of their time interacting with people directly. Monitor to see if concerns have been ignored and played down if the managers recognised the impact of violence on everyone in the service and how managers respond to bullying between members of the team.
• Experience of service users – If service users don’t appear comfortable with staff or they're anxious around them, staff have been known to tease them or touch them inappropriately or staff use unnecessary physical restraint, then it could be a sign of abuse. The way the staff handle the way they are treated by service users is also important. For example, do they tolerate abusive language or inappropriate physical contact correctly?
• Skills and experience of staff – The staff should know the service users and their plans pretty well, such as their health, routine and the food they like. They shouldn’t use disrespectful language to the service users or behind their backs and they must never see them as a problem. Care should be consistent and will often reflect in the appearance and physical health of the service users.
• Use of restrictions and restraints – If there are imposed restrictions in place, they must be reviewed often so they remain a proportionate response to risk. Examples of this include rooms being locked and off limits to service users, giving them limited control over their living space, and restricted access to equipment that may be locked away by staff or kept out of reach.
• Safety of the environment – A good environment is a positive sign as it can reflect how much care is taken towards service users. For example, a building that’s dirty or in a state of disrepair, and rooms that aren’t personalised to the service users' preferences and needs could be a sign of a lack of interest or care towards their happiness and safety.
• Oversight – If there is a high or increasing number of safeguarding incidents, complaints, etc. this could be a sign of a closed culture in care. Especially if the incidents involve inappropriate behaviour toward service users by staff, injuries and lack of privacy to services users, violence by service users aimed at staff, police involvement and visitor complaints.

One question that you may ask is how providers respond to and eliminate closed cultures. Well, CQC has proposed a list of ways to do so in their new strategy. The first step is to get all providers to practice a safe culture. This means promoting a culture of openness, accountability and transparency. It should allow staff to learn from their mistakes without fearing the loss of their jobs while encouraging whistleblowing in health and social care.

Closed Cultures CQC

To tackle closed cultures, the CQC (Care Quality Commission) has produced guidance for their inspection terms and Mental Health Act reviewers to help them identify a closed culture in care at the earliest opportunity. This allows them to take appropriate action to reduce the chances of the recurrence of abuse and protect everyone within the service.

Incident Risk Factors

The way CQC determines the likelihood of a care service developing a closed culture will increase if more than one of the following risk factors are present:

• Service users have become highly dependent on staff to meet their basic needs.
• Service users have hospital stays that last months or years.
• Certain characteristics in staff such as lack of training, limited access to professionals, high staff turnover and expected to work long hours with excessive overtime.
• Poor feedback from staff or ex-staff, service users and/or visitors.
• Lack of meaningful external scrutiny such as a geographically isolated service where service users are far from home and feel isolated and poor reporting of concerns alongside limited contact with the local authority.
• Signs of weak or poor management within the care services e.g.
  • Significant changes in management over short periods.
  • Increased use of non-permanent staff.
  • Failure to provide sufficient staff supervision.
  • Bad response to any complaints.
  • Family members employed in management roles.

However, the above risk factors aren’t proof that there is an abusive culture, but it could be a sign of more to come. So the care service should be monitored closely.

How to Respond to a Closed Culture System

When a care service is being monitored, or if an inspection is being planned, teams need to consider if people can self-advocate, if there’s a high inherent risk and whether there are any warning signs of a closed culture.

The CQC Guidance will give inspectors pointers on how to monitor a care service and conduct an inspection on places that may have a high inherent risk or that have clear warning signs. For responsive inspections, a low threshold is advised.

Our A-Z of Regulation and Compliance series of guides has been created to disentangle key information from the jargon and cut through vague statements to help you gain clarity on what you should be doing in your care service. Check out Issue 3: C is for Closed Cultures, which goes into more detail on how you can prevent, identify and tackle a closed culture within your care service.

Can Software Reduce Closed Cultures in Care? 

To summarise, closed culture in a health or care service increases the risk of harm to people, including staff and service users. Harm could class as abuse and breaches of human rights. Whether the closed culture is deliberate or unintentional, they can all lead to unacceptable harm that can be avoided with the right management, guidance and help from the CQC or local authority.

At The Access Group, we understand the importance of an open culture and advise implementing methods to encourage good practice within your care service. We strongly recommend implementing Access Policies and Procedures and Access Care Compliance software throughout your care service to improve the safety and happiness of your team and service users.

With Policies and Procedures, you can easily manage all of your documents, forms, policies and procedures for your care service and rely upon expertly written policies and procedures that are updated regularly. The software also includes a mobile app meaning care workers always have access to the right policy or procedure, at their fingertips, wherever they are.

While Care Compliance empowers you to monitor and improve governance and regulatory compliance across all your care services. You can use the software to audit all your services for closed culture, or indicators of them, and allocate out any necessary actions to address this. All from the comfort of your desk using the simple, powerful interface. Both platforms are suitable for care services of all sizes, and they enable you to deliver joined-up care and focus on care quality, control of care operations and efficiency of care services. You can get in touch for more information on each care management solution, and try before you buy with our demo.