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Our work on closed cultures

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  • Public

This project looks at how we will check for and tackle closed cultures in services.

A closed culture is a poor culture in a health or care service that increases the risk of harm. This includes abuse and human rights breaches. The development of closed cultures 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
  • people stay for months or years at a time
  • there is weak leadership
  • staff lack the right skills, training or experience to support people
  • there is 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.

Why are we doing this work?

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/or 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, such as Transforming Care which has tried to move people with a learning disability out of hospital and into community services.

We have been concerned about the quality and safety of mental health and learning disability wards for a long time. We have highlighted examples of our concerns in reports to government, including our State of Care in Mental Health Services 2014–2017 report. 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 in 2019 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 regulate these services.

To inform our new approach to in these services, we commissioned two reviews by David Noble and Professor Glynis Murphy to look at how we could improve our regulation. These reviews 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.

Guidance for inspectors

We have released new guidance for inspectors on closed cultures. This is will enable CQC to better 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.

All inspectors and regulatory colleagues will be required to undertake a series of training sessions throughout summer 2020 on the guidance and closed cultures more broadly.

What do we want to achieve?

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 for monitoring and inspection
  • 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

What have we done so far?

In May 2019, we released an interim report about how restrictive practices are used in the care of people with a learning disability, a mental health condition or autistic people. We worked with an Expert Advisory Group to develop the content of the report and made the voice of people and human rights central. This highlighted again that the system of care for people in these services is not fit for purpose and must improve. We will be publishing a further report in Autumn 2020.

In June 2019, in response to Whorlton Hall, we commissioned two independent reviews to look at how we could improve our approach to regulating services like this.

On 10 October 2019, we wrote to providers of mental health and learning disability services to ask them to consider how the system can better protect people who have a learning disability, autism and or mental health problem in their service.

In November 2019, we produced our initial supporting information for our inspectors about how to inspect services that may have closed cultures.

In January 2020, the first independent review was published by David Noble. He made seven recommendations including: improving the security and availability of notes from CQC inspections; improving information provided to inspectors about services; better quality assurance processes; legal policies and process improvements around the internal whistleblowing process and how CQC investigates complaints from providers. CQC accepted all of these recommendations.

In March 2020, the second independent review was published by Professor Glynis Murphy. This is part one (out of two) of the review, and made six recommendations including improved displaying of data, increased unannounced and evening inspections, improving responses to abuse allegations, prioritising the views and experiences of people using services and families, having a more flexible approach, and not registering unsuitable services. CQC accepted all of these recommendations.

In April 2020 we set up a dedicated team to incorporate these recommendations into CQC policy, and to work with external stakeholders, including people who use services, families and others to co-produce changes we make.

In June 2020, we are releasing new guidance for inspectors on closed cultures, to further strengthen our approach, and following COVID-19 exacerbating these issues for certain people.

This work will shape our next strategy and inform fundamentally how we work as a regulator.

Over the next year we will be reviewing our methodology and the tools our inspectors use to strengthen these from a closed culture perspective.

How you can get involved

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 that 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, email closedculturesengagement@cqc.org.uk to request 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, email the above address to arrange a phone call to discuss how you can be involved.

Email culturesengagement@cqc.org.uk to sign up to our mailing list to be kept up to date with the work via regular blogs, and news stories.

Sign up to our online platform to take part in surveys, reviews of reports, and more.

Last updated:
23 June 2020