This is the 2020/21 edition of State of Care
A closed culture is ‘a poor culture that can lead to harm, including human rights breaches such as abuse’.
In these services, people are more likely to be at risk of deliberate or unintentional harm. This risk has been further exacerbated during the pandemic by more services becoming closed environments due to a lack of visitors, and from the potential impacts of staffing and management pressures.
‘I may have been unwell, but I knew what was happening was wrong’
When I was a patient in a closed culture on a psychiatric ward, I felt completely vulnerable. The staff had all the power and I felt that whatever I did or said I was completely powerless. Some of the senior staff were so arrogant that they controlled everything. I could tell that some of the more junior staff disagreed with what was happening, but even they didn't feel able to speak up for the patients' rights (and presumably for their own working environment too). Even when I did try to say that things weren't safe, I was ignored. It felt like all my experiences, past education, training and work counted for nothing because I was the one who was mentally ill and they were the ‘professionals'. I may have been unwell, but I still knew that what was happening was wrong and was rejected when I tried to articulate this to the ‘powers' in the organisation.
We are committed to improving our regulation of services where there is a closed culture or is a high risk of a closed culture developing. As part of this, we will continue to review whistleblowing concerns, feedback about the quality of care from people using services and their carers and staff, and notifications that services must send us – to proactively identify services we think could be at risk of developing a closed culture. We also continue to review these risks through our work and our visits to services to monitor the operation of the Mental Health Act.
In our July 2021 Insight report, we shared our learning from a sample of 29 inspections where we have found evidence of closed cultures. In this, we identified the six common features of closed cultures:
- incidents of abuse and restrictive practice
- issues with staff competence and training
- cover-up culture
- lack of leadership and management oversight
- poor-quality care generally
- poor-quality reporting.
While closed cultures can develop in any type of health and care setting, we are particularly aware of the increased risk in services that care for people with a mental health condition, people with a learning disability and autistic people.
Through our remote reviews of high-risk mental health services, as well as through engaging with others to hear from people who have had experience of closed cultures, we are concerned that people continue to be put at risk.
Our concerns include:
The use of restrictive practices
“No clothes, just a hospital thing, I didn’t have a telephone, because they had taken my telephone, you’re not allowed telephones on the ward for security reasons, no money, no medication, nothing.”
People should be given options and control over as much as possible when in hospital. With many of their freedoms already restricted, not giving people the ability to choose activities and what time to go to sleep can make them feel trapped.
We heard that individual incidents for a specific person had been used to justify the introduction of blanket bans, without individual risk assessments. For example, one service had introduced a blanket ban on access to mobile phones because of one individual allegedly using her phone to film staff and patients.
We also heard of staff using punitive approaches where patients had to earn ‘privileges’, such as access to fresh air. These privileges could also be removed in punishment. In one example, an informal patient was threatened with being detained under the Mental Health Act if they tried to leave the ward.
Issues with staffing and management
Poor leadership styles and approaches to providing care can lead to closed cultures. These approaches often get transported around different care settings as staff teams shift locations and job roles.
We were particularly concerned about services having a lack of staff, which may suggest a lack of planning from managers. It also suggests that they may be trying to run the services with the minimum number of staff and not fully considering the needs of individuals, such as ‘off-ward’ activities. In addition, we heard how the use of bank or agency staff meant people were not always cared for by staff who were familiar with the setting or with their personal needs and preferences.
Not having enough staff, or employing staff without the right skills, knowledge and attitude can affect the safety of people using the service. It could also have an impact on people’s quality of life. For example, it can restrict people from being able to go out into the community as people often need staff support to do this.
Lack of external oversight
The outbreak of the COVID-19 pandemic increased the risk of closed cultures developing, as restrictions introduced in response to the pandemic prevented external bodies, such as reviewers, and friends and family from visiting.
In services with closed cultures where adequate care is not being provided, families can feel forced to take on care responsibilities. Not only can this cause unnecessary stress, when family members have caring responsibilities, they may feel in denial about their own health concerns, meaning their conditions can go ignored and untreated.
Through our reviews, we were concerned that services were not proactive enough in communicating changes due to COVID-19, such as restrictions on visiting, to patients, relatives and staff. As a result, the impetus fell on relatives to chase for updates on the care of their loved ones, and when those updates were received, they weren’t always detailed enough.
Where we find concerns about a service, we continue to monitor them as part of our ongoing regulation.
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.
As an organisation, we are continuing to improve our regulation of services at risk of developing a closed culture. We are testing a new methodology that is designed to get under the culture of a service and better 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. Human rights are at the heart of our new approach, and we will always look at services from the perspective of people using them.