Message from Kate Terroni

Update on our closed cultures work and new guidance for inspectors

Kate Terroni, Chief Inspector of Adult Social Care, sets out our next steps to support our inspection teams to improve how we identify and respond to services at risk of developing closed cultures.

Today we are releasing new guidance for our inspection teams on closed cultures and I want to use this as an opportunity to update you on our closed cultures work. I’m the social care lead for CQC and also leading this work across all sectors.

The new guidance we are releasing will support our inspection teams to continue to improve how we identify and respond to services that might be at risk of developing closed cultures. We worked with people who use services, Experts by Experience, families, Local Healthwatch and stakeholders to produce this.

A closed culture is a poor culture which has an increased risk of harm — including abuse and human rights breaches. This can be deliberate or unintentional — either way it can cause unacceptable harm to a person and their loved ones.

Closed cultures are more likely to develop in services where people are removed from their communities, where people stay for months or years at a time, where there is weak leadership and where staff often lack the right skills, training or experience to support people. They are also more likely to develop where there’s a lack of positive and open engagement between staff and with people using services and their families.

In these services, people are often not able to speak up for themselves — this could be through lack of communication skills, lack of support to speak up or abuse of their rights to speak up.

It’s important that we openly recognise where this work came from and why we’re doing it. A closed culture can develop anywhere but we know that there are certain services and groups of people that will be at greater risk. This includes services that provide care for people with a learning disability and autistic people, and older people who may not have regular contact with families. These issues are not new, and are complex — this has been evidenced by the events at Winterbourne View in 2012 and the government’s response to this, such as Transforming Care, which have tried to move people with a learning disability out of hospital into community services.

We have been concerned about the quality and safety of mental health and learning disability wards for a long time and have highlighted examples of the concerns we have in our reports to government including our State of Care in Mental Health Services 2014–2017. Following this, NHS England set up several programmes to reduce restrictive practices and we were commissioned by the Secretary of State for Health and Social Care to conduct our own review of restrictive practices.

The BBC Panorama programme last May on Whorlton Hall highlighted shocking abuse of people with a learning disability and autistic people in hospitals, reinforcing the need for rapid improvements in care. As well as emphasising that this is not the right model of care for people, Whorlton Hall emphasised how difficult it is to identify abuse, and fundamentally challenged us to re-think the way we regulate these services.

To inform our new approach to in these services, we commissioned two reviews by David Noble and Professor Glynis Murphy to assess how we could improve our regulation. These made several recommendations that we will be delivering through this work. However, over the last year we highlighted that ‘closed cultures’ can develop in any service, so the learning from this will be reflected in how we regulate all aspects of health and care.

What do we want to achieve with closed cultures work?

In this work we really want to focus on some key things, and these may change over the course of the year as new issues arise:

• We want to improve our ability to hear from people who use services in closed cultures, give more weight to what they tell us, and then improve our ability to act on their concerns.
• We want our inspectors to be able to effectively identify where there’s a closed culture and be able to prioritise these services
• We want to continue to embed human rights into the work our inspection teams do
• We want to improve our ability to collect and use intelligence to inform our understanding of these risks
• We want to use the information we gather through our inspection activity and elsewhere to work with and influence system partners to the changes that are outside of CQC’s remit.

How you can get involved — we need your help

We are committed to working with people who use services, families, providers, frontline staff and other stakeholders to improve the way we inspect closed cultures.

One of the ways we will be involving people in this work is through an Expert Advisory Group. We are looking for people who are able to join the group from the very start in order to influence the work and provide constructive challenge throughout. We will be giving more details about this group in the next month, but we want to let you know it is coming.

We are looking for people who have the following experience, this can either be through lived experience or through professional expertise:

• Hospitals that care for autistic people or those with a learning disability
• Mental health hospitals, where people are detained under the Mental Health Act
• Services that use Deprivation of Liberty safeguards through the Mental Capacity Act including social care services.

We will be allocating places via an Expression of Interest process. If you would like to be considered for this advisory group, please contact: closedculturesengagement@cqc.org.uk to receive a form and more information.

We do not want there to be any barriers to you participating in the work. If you have accessibility requirements, please email the above address to arrange a phone call to discuss how you can be involved.

If you would like to be kept up to date with the work via regular blogs and news stories, please email closedculturesengagement@cqc.org.uk to sign up to our mailing list.

If you would like to be part of our online platform as the project develops, please sign up here: https://cqc.citizenlab.co/en-GB/sign-up. This will include things like surveys and reviews of reports.