Observing the culture in mental health services

Care Quality Commission
3 min readMar 30


Woman in counselling session

In this blog Chris Dzikiti, Director for Mental Health, updates on the work we’re doing to get beneath the culture in high-risk mental health services.

In a recent blog I talked about good regulation being the cornerstone of achieving high-quality care. Unfortunately we know that despite the best efforts of so many people across the system, there are still people in mental health services who are not receiving the care they need or deserve. We’re all aware of the tragic events that took place at Whorlton Hall, Edenfield and Winterbourne View, and unfortunately now also shown in the recent Dispatches programme, and as the regulator we have a responsibility to continuously better our understanding of the culture of high-risk services like these.

We want to ensure people on mental health wards are safe and their human rights are protected. To do this, we’re working to improve the approach we take when inspecting these wards. We need to really get beneath the culture and identify where closed cultures and restrictive practices exist. We believe that observation can be a key tool for this. Currently we don’t use observation to its full potential during our usual inspection activity. Our plan is to develop an observation programme involving short inspections of wards. We’ll focus on the safety of cultures in core services or locations that have been identified at greatest risk of developing closed cultures and using restrictive practices inappropriately. Firstly, we need to test out the use of observation as a tool.

What we’ve done so far

Since February 2023 we’ve been using planned unannounced inspections to test the use of the Short observational framework for inspection (SOFI) tool. SOFI was developed to help our inspectors capture the experiences of people who use services who might not be able to or feel comfortable to express this for themselves. Observations don’t replace talking to people who use services, and in our testing phase we’ve also involved our Experts by Experience on visits. We hope that by using SOFI our inspectors can observe the mood, the level of engagement with people using services, and the quality of their interactions with staff.

We want to learn from the testing of this approach, so that when we begin the full programme of work later in the year we’re confident that we have the right tools to get the most out of our visits. When our testing phase is complete, we’ll engage with our stakeholders, reviewing the positives and negatives of the approach, to shape the development of the full framework and inspection programme. So far, we’ve talked to people who use services, clinicians, our national professional advisors and specialist advisors to develop the methodology and plans.

Next steps

Later in the year we plan to roll out a full programme of unannounced standalone visits, using the methodology we’re developing specifically for this work. The full framework will focus on our key questions about whether a service is safe, caring and well-led. It will allow us to report differently on the culture within organisations. The visits will be risk based and targeted, meaning we can improve reports and influence discussions on culture and restrictive practices.

I’ll write more blogs in the coming months to update you on the feedback from the testing phase, the progress in finalising our methodology, and the plans going forward. You can also sign up to our provider bulletin and digital engagement platform, Citizenlab, to be the first to hear about opportunities to get involved.

Ultimately, this is about keeping people safe, and I truly believe this will go some way towards doing just that.



Care Quality Commission

We make sure health and social care services provide people with safe, effective, compassionate, high-quality care and we encourage care services to improve.