Our closed cultures project worked to improve our regulation of services that are at a higher risk of poor care and abusive cultures. It also looked at ways to encourage best practice and improvement in the health and care system.
This update looks at the progress made, and our evaluation of the project.
The aims of the project were for us to:
- understand the features of a closed culture and the factors that might lead to the development of one.
- make sure we can detect closed cultures and services likely to develop such a culture.
- develop a variety of tools including intelligence, inspection, surveillance and engagement
- improve ways to prevent closed cultures from developing.
- stop services that do not provide the right care models from registering.
- promote best practice
- support providers to improve and hold them to account.
2014 – 2017
We completed our first full round of inspections of services caring for people with a learning disability, mental health condition and/or autistic people.
We found that there were 7 key areas that needed significant improvement. One of these was the use of restraint and segregation, and another was the physical environment in mental health hospitals.
The Secretary of State for Health and Social Care asked us to conduct a review of restraint, segregation and seclusion across mental health hospitals in England.
We published our interim report for this review in May 2019 and our final report, Out of Sight - Who Cares?, in October 2020.
A BBC Panorama programme on Whorlton Hall, a hospital in Durham, showed the need for rapid improvements in care. The programme challenged us to re-think the way we regulate these types of service.
Since then, we have worked to improve the way we monitor and regulate services that may be at risk of a closed culture.
We commissioned two independent reviews following Whorlton Hall:
- David Noble QSO looked at how we dealt with concerns raised in relation to the regulation of Whorlton Hall
- Professor Glynis Murphy looked at whether the abuse of patients at Whorlton Hall could have been recognised earlier
We also set up our own closed cultures project to begin work on making improvements.
Both the Glynis Murphy review and our work found that services caring for people with a learning disability and autistic people were at a higher risk of a closed culture.
This work would not have been possible without the input from internal and external expert advisory groups. These are groups of people who use services, families, providers, commissioners, national bodies, voluntary sector partners and our regulatory colleagues. Their knowledge and experiences shaped this work from start to finish.
There are a number of ways that we have improved how we identify and take action on closed cultures.
Better intelligence collection and analysis
We have improved the way we collect and analyse data from people who may be receiving care in a closed culture service.
We have run several targeted campaigns promoting Give Feedback on Care. This is an accessible online service that helps people tell us about their care.
We have developed a dashboard to check services that care for people with a learning disability and/or autistic people. We use the dashboard to watch for risk and inform our enforcement activity. As part of this work, we have developed risk indicators for closed cultures. We have embedded this work into our regulatory process. We rolled out the first set of indicators to inspectors at the end of 2021 and we will check their effectiveness. In 2021, we saw a 20% rise in the number of people coming forward with whistleblowing enquiries for services caring for people with a learning disability and/or autistic people. We also saw a 25% increase in enforcement action.
Enhanced inspections and methods
We have improved the ways we check the culture of a service. Observation is key, whether it's through talking with staff and people in the service, or with tools.
Our quality of life tool helps inspectors see where effective care planning is taking place. The tool was developed following recommendations from Glynis Murphy's review.
On some of our inspections we also use a tool called the short observational framework for inspection (SOFI). This helps inspectors to capture the experiences of people who use services who may not be able to express this for themselves.
Our closed cultures guidance recognises the need for unannounced and out of hours inspections where there is a risk of a closed culture.Between April 2021 and January 2022, 56% of our new learning disability and autism inspections included out of hours inspections.
We rolled out training on identifying and responding to closed cultures to 2,000 operational colleagues.
We gave extra training to over 1,400 colleagues before they inspected services that autistic people might be using.
We have developed a suite of tools to help our inspectors reach people who have communication difficulties. This includes training on PECS (Picture Exchange System), MAKATON and British Sign Language. We are also piloting the use of Talking Mats. Further training is being rolled out to our regulatory colleagues in these areas.
Research into closed cultures
In 2020, we attended an international research symposium organised by Professor Glynis Murphy looking at how to better detect closed cultures. The findings of the symposium highlighted the need for future research.
Our proposal for research into the factors that lead to an abusive culture has been approved for scoping by the Department of Health and Social Care’s Research and Development Committee.
We have improved our ability to detect poor care for people in closed cultures. As a result, we have been able to take more action against services. But there is more to follow, including how we embed improvements into our future work.
We will make sure that we continue to have oversight of services that care for people with a learning disability and/or autistic people.
We are clear that our work does not stop here. Tackling closed cultures continues to be a priority for us.
Our evaluation of the project
Our research and evaluation team looked at how well the changes made by the project worked.
The key findings were:
- CQC colleagues clearly view this work as fundamental to what we do.
- There is a good level of awareness of closed cultures across the organisation. Our survey showed over 70% of colleagues agreed that their team has a good understanding and awareness of closed cultures risk.
- Operational colleagues have increasing confidence about identifying and preventing closed cultures.
- We saw that taking action in response to cases is a serious undertaking, requiring persistence and diligence from operational colleagues.
- CQC colleagues often referred to ‘gut feelings’ around the risk of a closed culture. Colleagues would base these views on their experience, training and knowledge of the service. This was not always something they could report and act on.
- CQC colleagues were clear that it is vital to cross the threshold of services to identify closed cultures.
- Pilots of specific tools to help colleagues get a greater understanding of people's experiences have been well-received. For example, the evaluation of the Talking Mats pilot found that colleagues felt the mats helped people share their views and experiences of care. A significant proportion of colleagues said they identified concerns about a person’s wellbeing or their care using the mats.
We made a series of recommendations to make sure the work continues beyond the life of the project.
- Continuing to increase understanding and awareness. We will make sure we apply our learning and tools to other service types, as we know closed cultures can exist in any kind of service.
- Reframing how we look at cultures to widen the relevance across operations.
- Giving colleagues extra information and support where needed. This includes helping colleagues with the use of communication tools and supporting colleagues to use their professional instinct effectively.
- Continuing to build on intelligence work by evaluating, monitoring and iterating the roll out of the intelligence dashboard.
- Making sure the closed cultures message and outputs continue through other key projects.