COVID-19 Insight 12: Identifying and responding to closed cultures

The abuse at Whorlton Hall, Winterbourne View, Mid Staffordshire Hospital and other services highlighted breaches of human rights that resulted from closed cultures, and the impact that these had on people using services.

We define a closed culture as 'a poor culture that can lead to harm, including human rights breaches, such as abuse'.

While there is no single factor that can lead to a closed culture developing, we know that there are certain risk factors. These include:

• people being placed in services far from their family, friends and communities
• people staying in inappropriate environments for months or years at a time
• weak leadership within a service
• staff not having the right skills, training or experience to support people
• poor culture, with a lack of positive and open engagement and communication between staff, and with people who use services and their families.

The development of closed cultures can be deliberate or unintentional – but either way it can cause unacceptable harm to a person and their loved ones.

In this article, we highlight what we have learnt so far about how risks can accumulate and build into a closed culture. We want to raise awareness of the warning signs so that care service providers and managers can take action.

Our work so far

Identifying and taking action on closed cultures is a central part of our regulatory work. In December 2020, we published the second part of Professor Glynis Murphy’s Independent Review into our regulation of Whorlton Hall.

We are currently implementing and incorporating these recommendations into CQC's operating model for high-risk services. We are doing this in collaboration with a wide range of stakeholders, including people who use services, families, voluntary sector organisations, providers and other groups, as well as our own staff.

We know that closed cultures, and the possibility of breaches of human rights, may occur across a wide range of health and social care settings. We also know that some services, such as places where people with a learning disability or autistic people live, are more at risk than others.

This risk has been further exacerbated during the COVID-19 pandemic, with more services at risk of becoming closed environments due to a lack of visitors, and the potential impacts of staffing and management pressures.

To improve our understanding of, and how we identify, the risks associated with closed cultures, we are proactively reviewing information we hold on services we think could be at risk of developing a closed culture. This includes reviewing whistleblowing concerns, feedback about the quality of care from people using services and their carers and staff, and notifications that services must send us.

Where we have identified services as having a closed culture, we have taken appropriate action. This has ranged from initiating focused inspections, issuing urgent notices to restrict admissions, placing services into special measures and, where necessary, ensuring people are relocated to other care services. In these cases we have worked with the local authority to find suitable alternative accommodation.

In cases where we have had concerns about a service, but we did not find evidence of a closed culture on inspection, we continue to monitor them as part of our ongoing regulation.

The learning shared in this article is based on a sample of 29 inspections where we have found evidence of closed cultures. These include services in both the independent mental health and adult social care sectors.

Common features of closed cultures

In this section we describe some of the common features of services where we have found evidence of closed cultures.

• Incidents of abuse and restrictive practice. People were not safe in some services – there were cases of violence between people using the service and evidence of people being abused by staff. Inspectors had concerns about unlawful restraint being used, meaning people were at risk of being harmed. Blanket restrictions were in place in some services, meaning care was not person-centred and people were not supported to have maximum choice and control over their lives.

  We received information that referred to people being treated in undignified and inappropriate ways, including mocking, threatening and dehumanising behaviour, as well as physical, verbal and emotional abuse. There were also indications of bullying between staff and between management and staff.

  We also heard about management refusing to provide personal protective equipment (PPE) at the start of the COVID-19 pandemic, before patients and staff showed symptoms of the virus.

• Issues with staff competence and training. Concerns about staff competence mostly related to people not being supported when experiencing distress. The recurrence of similar incidents highlighted poor record keeping, poor communication between staff, and a lack of person-centred care. It also suggested that the process to identify and meet training needs was poor.
• Cover-up culture. Some services were not transparent about incidents or concerns raised by staff or people using the service. This included claims of under-reporting of violence between people using the service, people being unable to access the police or social workers following cases of abuse, and managers being unwilling to investigate concerns. Staff were not encouraged to speak up and in some services staff were told not to report incidents or raise concerns. In some services, managers had a defensive attitude and tried to blame others when we raised concerns about the standard of care.

• Lack of leadership and management oversight. Services did not appear to learn from incidents or act to prevent future incidents. We heard about management prioritising staff retention over people’s care needs, by failing to address poor staff performance.

  Managers were not accessible to those using the service, choosing not to attend care meetings or go on a ward. Notifications were sometimes submitted in a defensive tone, aiming to shift guilt from the service onto the people in their care.

  We found risks repeated across services at a regional and corporate provider level. This suggested that providers did not have reasonable oversight of their services or appropriate mechanisms for improvement.

• Poor-quality care. A lack of person-centred care was frequently reported, with care plans lacking detail about people’s needs. People’s individual needs, in particular in relation to their specific communication and sensory needs, were not clearly reflected in their care plans. This resulted in people being given inappropriate care and subject to increased levels of restrictive practice.
• Poor-quality reporting. Issues ranged from a lack of reporting to delayed notifications. While quality of reporting alone is not necessarily an indicator of a closed culture, and most cases of poor-quality reporting were not seemingly intentional, there were some concerns that notifications were delayed on purpose. Deliberate attempts to conceal issues, either from CQC or from higher-level management, are an indication of a culture within a service or provider that fails to promote safety and honesty and to implement improvements.

Next steps

We know that the COVID-19 pandemic has led to increased pressure on services, as well as fewer people visiting services, which makes the development of closed cultures at all services possible.

We want our regulation to be driven by what people expect and need from services. As a result, we are testing a new methodology that is designed to get under the culture of a service and really understand what it is like for people who live there. This includes using feedback more effectively and addressing concerns quickly when the risks of a closed culture are found.

While closed cultures can develop in any type of health and care setting, we are particularly aware of the increased risk in services for people with a learning disability and autistic people.

As an organisation, we know that our regulation of services that care for people with a learning disability and autistic people needs to improve. In response to this, we are carrying out a year-long programme of work to transform the way we regulate services for people with a learning disability and autistic people.

Above all else, we want to make sure that services for people with learning a disability and autistic people are good. To do this, we are focusing on three key areas:

• Registering the right services – I use services that support me in the way I want to live and where I want to live.
• Supporting providers to improve – I will not be asked to move to a service that isn’t safe, I won’t be expected to continue to live in a service that doesn’t meet my needs.
• Influencing the improvement of care pathways and ensuring that people are receiving the right care at the right time – I can access local services that meet my needs and get the right healthcare when I need it.