Being Open & Duty of Candour

Our Being Open & Duty of Candour policy details how we improve the safety of, and communication to, our beneficiaries.

Introduction

Purpose

Homefield College has a genuine commitment to greater openness and candour, to developing a culture dedicated to learning and improvement, which constantly strives to reduce avoidable harm.

Homefield College is committed to improving resident safety and communication with residents and / or family members / carers when a resident is involved in an incident, which includes moderate harm, (nonpermanent harm) severe harm or death. We will also ensure that residents, their carers or family where appropriate, are kept informed of the investigation and any outcomes, with the opportunity to ask questions.

The publication of the Francis Inquiry report in 2013 instigated many changes to health and social care providers, including the drive to improve transparency and openness and to provide assurance to our residents that we are doing everything we can to keep them safe.

A statutory duty of candour came in in November 2014 for NHS trusts in addition to registration requirements with the Care Quality Commission (CQC).

Open and effective communication with residents begins at the start of their care and should continue throughout their time within the care system. This should be no different when a resident safety incident occurs, when a resident makes a complaint, or in the case of a lawsuit, claim or litigation.

Being open and our duty of candour relies initially on our staff and the rigorous reporting of resident safety incidents. Homefield College endorses the Francis Report recommendation 173 and aims to promote a culture of openness, which it sees as a prerequisite to improving resident safety and the quality of residents’ experience.

Scope

This policy only relates to those incidents, complaints and claims where a resident (or more than one resident) has been harmed, or has the potential to be harmed, as a direct result of when things have gone wrong.

Homefield College encourages staff to report all resident safety incidents, including those where there was no harm, or near misses, via the organisation’s incident reporting and safeguarding reporting systems, using the principles set out in the Safeguarding Policy.

Any staff who are concerned about the non-reporting or concealment of incidents, or about on-going practices which present a serious risk to resident safety, are encouraged to raise their concerns under Homefield’s Whistleblowing Policy.

Definitions

Below is a list and the meaning of key terms that appear within this document.

Being Open – Being open is a set of principles that staff should use when communicating with residents, their families and carers following an incident in which the resident was harmed or had the potential to be harmed.

Candour – Candour is the quality of being open and honest. Residents, or someone lawfully acting on their behalf, should as a matter of course, be properly informed about all of the elements of their treatment and care.

Care Quality Commission (CQC) – The independent regulator of health and social care in England.

Duty Of Candour – Our statutory duty to follow a specific process in being open when a resident safety incident results in moderate harm, severe harm or death.

Root Cause – “A systematic process whereby the factors that contributed to an incident analysis are identified. As an investigation technique for resident safety incidents, it looks beyond the individuals concerned and seeks to understand the underlying causes and environmental context in which an incident happened”.

Prolonged psychological harm – Psychological harm which a service user has experienced, or is likely to experience, for a continuous period of at least 28 days.

Application of Being Open & Duty of Candour

This section informs you of how Homefield applies the Being Open & Duty of Candour policy.

Incident Level of Harm – Which Process Applies

Certain processes apply depending on the level of harm.

No Harm

Incident prevented – any resident safety incident that had the potential to cause harm but was prevented, and no harm was caused to residents receiving care.
Incident not prevented – any patient safety incident that occurred but no harm was caused to patients receiving NHS-funded care.

Process = There is no requirement to report these incidents to residents / relatives. The decision of whether to communicate these to residents / relatives depends on circumstances and advice should be sought from the Safeguarding or Senior Management team.

Low Harm

Any resident safety incident that required extra observation, or minor treatment and caused minimal harm to one or more patients, receiving care. Minor treatment is defined as first aid, additional therapy, or additional medication. It does not include any extra stay in hospital or any extra time as an outpatient, or continued treatment over and above the treatment already planned; nor does it include a return to surgery or readmission.

Process = Low harm incidents should be communicated to residents / relatives through the safeguarding procedure.

Moderate Harm

Any resident safety incident that resulted in a moderate increase in treatments and which caused significant but not permanent harm, and or prolonged psychological harm, to one or more residents receiving care. Moderate increase in treatment is defined as a return to surgery, and unplanned readmission, a prolonged episode of care, extra time in hospital or as an outpatient, cancelling of treatment or transfer to another area, such as intensive care as a result of the incident. Prolonged psychological harm which means psychological harm a service user has experienced, or is likely to experience, for a continuous period of at least 28 days.

Process = Being Open principles and application of Duty of Candour process.

Severe Harm

Any resident safety incident that appears to have resulted in permanent harm to one or more persons receiving care. Permanent harm directly related to the incident and not related to the natural course of the resident’s illness or underlying condition is defined as permanent lessening of bodily functions, sensory, motor, physiological or intellectual including removal of the wrong limb or organ, or brain damage.

Process = Being Open principles and application of Duty of Candour process. Serious Incident requiring investigation process. (Root Cause Analysis)

Death

Any resident safety incident that directly resulted in the death of one or more persons receiving care. The death must be related to the incident rather than to the natural course of the resident’s illness or underlying condition.

Process = Being Open principles and application of Duty of Candour process, as well as Serious Incident Requiring Investigation Process.

Understanding the Being Open principles

Being Open recognises that everyone has the right to be treated with respect and to receive fair and dignified treatment. Being Open enables Homefield to fulfil its duties to promote human rights in a practical, day-to-day level. It particularly enables Homefield to promote the right to a fair trial and the right to freedom of expression.

Residents are more likely to forgive errors if they are discussed fully and in a timely and thoughtful manner using the Being Open policy. By Being Open, staff can lessen the trauma felt by residents following a resident safety incident.

Being Open involves:

  • Acknowledging, apologising and explaining when things go wrong;

  • Conducting a thorough investigation into the incident and reassuring residents, their families and carers that lessons identified will help prevent the incident recurring;

  • Providing support for those involved to cope with the physical and psychological consequences of what happened.

In addition to application of Being Open policy, our statutory duty of candour requires a formal process, which is explained in the next section.

The Benefits for Residents

Our residents receive a sincere apology and explanation when things go wrong and this will support:

  • Feeling their concerns and distress have been acknowledged;

  • Reassurance that Homefield will identify lessons to prevent harm happening to anyone else;

  • Reducing the suffering felt when things go wrong;

  • Improving respect and trust for the organisation;

  • Reassurance treatment and care will continue according to clinical/care needs.

The Benefits for Homefield and our Staff

Being Open not only benefits residents, their families and carers, but also staff and care organisations.

For care organisations and teams, the benefits are:

  • An enhanced reputation of respect and trust for the organisation / service / team;

  • A reinforced culture of openness;

  • Improving the residential experience and satisfaction;

  • A reputation for supporting staff when things go wrong;

  • The opportunity to learn when things go wrong;

  • The potential to reduce the costs of litigation.

For our staff, the benefits are:

  • Confidence in how to communicate effectively when things go wrong;

  • Feeling supported when apologising or explaining to residents, their families and carers;

  • Satisfaction that communication with residents and/or their carers following a resident safety incident has been handled in the most appropriate way;

  • Improving the understanding of incidents from the perspective of the resident and/or their carers;

  • The knowledge that lessons identified from incidents will help prevent them happening again;

  • Having a good professional reputation for handling a difficult situation well and earning respect among peers and colleagues;

  • Residents are more likely to forgive errors if they are discussed fully and in a timely and thoughtful manner using the Being Open policy. By Being Open, staff can lessen the trauma felt by residents following a resident safety incident.

NPSA 10 Principles of Being Open

Our policy follows these 10 principles.

  1. Acknowledgement – All resident safety incidents should be acknowledged and reported on via the safeguarding procedure as soon as they are identified.

  2. Truthfulness, timeliness and clarity of communication – An appropriately nominated person must give information about a resident safety incident to residents, their families and/or their carers in a truthful and open manner.

  3. Apology – Residents, their families and/or their carers should receive a sincere expression of sorrow or regret for the harm that has resulted from a resident safety incident, i.e. a meaningful apology. Saying sorry to residents, their families and/or their carers is not an admission of liability.

  4. Recognising resident and carer expectations – Residents, their families and/or their carers can reasonably expect to be fully informed of the issues surrounding a resident safety incident and its consequences, in a face-to-face meeting with representatives from the organisation.

  5. Risk management and systems improvement – Root Cause Analysis or similar incident investigation techniques will be used to uncover the underlying causes of all relevant resident safety incidents. All investigations should focus on improving systems of care, which will then be reviewed for their effectiveness.

  6. Professional support – Homefield will create an environment in which all staff, whether directly employed or independent contractors, are encouraged to report resident safety incidents. Homefield will ensure staff are supported throughout any incident investigation, as we recognise that they may have been affected. We will not unfairly expose staff to punitive disciplinary action.

  7. Multidisciplinary responsibility – The organisation’s Being Open policy will apply to all staff who have key roles in a resident’s care.

  8. Clinical governance – Being Open requires the support of the organisation’s resident safety and quality improvement processes, in which resident safety incidents are investigated and analysed to find out what can be done to prevent their recurrence.

  9. Confidentiality – The organisation’s Being Open policy should give full consideration of, and respect for, the privacy and confidentiality of residents, their family and/or carers and staff, in line with the CQC’s 5 key questions (are services safe, effective, caring, responsive and well led?).

  10. Continuity of care – Residents are entitled to expect that they will continue to receive care and treatment and to be treated with dignity, respect and compassion. If a resident’s healthcare needs are to be taken over by another team, appropriate arrangements should be made for transition of care to the new team.

Applying the Statutory Duty of Candour

Step 1.
Incident is identified (Moderate or Severe Harm) An incident may be identified by a resident, a carer, a staff member or an independent contractor. Support must be given to the resident and staff affected.

Following an incident, the resident should continue to receive care and treatment and should continue to be treated with respect and compassion by staff. Should the resident wish to receive treatment from another organisation, arrangements should be made to facilitate this wish, if possible. Residents / relatives / carers should be reassured that the incident and its investigation would not affect the continuing care and treatment provided.

Step 2.
Record incident through the safeguarding process and inform the Senior Management Team. The Duty of Candour box on the Safeguard incident reporting form must be ticked for all Duty of Candour reporting and monitoring purposes.

Step 3.
Discussion with Senior Management Team – A member of the Safeguarding Team should discuss the incident with a Senior Manager and, the incident should be reported to the Trustees if appropriate. The team must agree on who will hold the initial disclosure discussion with the resident and / or their family and when this will take place.

Step 4.
Initial Disclosure and Verbal apology – A member of the Safeguarding Team should confirm to the resident/relative/carer that an incident has occurred and that this will be investigated. The initial discussion with the resident and/or their carers should occur as soon as possible after recognition of the resident safety incident and must be within 10 working days of the incident occurrence. A verbal apology for any distress or harm should be offered at this point as well as written notification confirming the disclosure.

Step 5.
Investigation – A member of the Senior Management Team carry out an investigation. In all cases the outcome of the investigation will be communicated in an ‘Investigation Findings and Apology letter’ reviewed by the Principal.

Step 6.
Outcome and Written Apology – After completion of the incident investigation, feedback should take the form most acceptable to the resident. The manager must contact the resident (or next of kin) within 10 working days on completion of the investigation review to offer to discuss the outcome of the investigation, including any learning. The investigation summary and ‘Investigation Findings and Apology letter’ should then be offered to the resident/relative/carer.

Step 7.
Feedback – The resident / relative / carer should be given the opportunity to respond to the findings with any feedback documented and responded to as required.

Step 8.
Action Plans – should be shared with the Senior Management Team.

Step 9.
Communication of Learning – Effective communication with staff is a vital step in ensuring that recommended actions are fully implemented and monitored and to increase awareness of resident safety and the value of Being Open. Team meetings, newsletters and the website are all available to help communicate with staff.

Factors to Consider

These following factors are important to consider when holding a candid Being Open discussion and meeting.

Disclosure Discussion

The purpose of a disclosure discussion is to inform a resident / family / carer that an incident has occurred and to offer an apology and sympathetic support. Verbal communication should always occur before a letter is sent. It is useful to identify an appropriate senior staff member to be a single point of contact.

It is important to avoid giving too much detail about the incident until the incident investigation has been completed.

The resident / family should be offered an opportunity to meet to discuss the details of the incident.

This is usually at the end of the investigation so that findings can be shared and discussed, but may also occur before the investigation starts, or during the process. The approach is agreed with the resident/family. The resident / family may request meetings at any stage during the investigation.

Resident / family concerns and preferences should be recorded and considered in the investigation.

A summary of the discussion and support needed will be made and followed up in writing using a template.

Practical Factors

Factors to consider before arranging a Being Open & Duty of Candour meeting include:

  • The clinical condition of the resident

  • Some residents may require more than one meeting to ensure that all the information has been communicated to and understood by them

  • The availability of key staff involved in the incident

  • The requirement for truthfulness, timeliness and clarity of communication

  • The availability of the resident’s family and/or carers

  • The availability of additional support, for example, an interpreter or an independent advocate, if required

  • Resident preference (in terms of when and where the meeting takes place and who leads the discussion)

  • The resident / relative / carer may express a preference regarding which staff should attend the meeting, this must be respected

  • Privacy and comfort of the resident

  • Arranging the meeting in a sensitive location

  • Saying sorry to a resident/relative/carer is not an admission of liability

Identify Support Needed

Residents / relatives / carers may need support from the organisation, an independent advocate or interpreter at any stage throughout the process and how to access these should be reiterated at regular intervals throughout the procedure. Staff should facilitate this process. If a resident is incapacitated because of the incident and does not have relatives/carers to assist them, an independent representative may be assigned.

Staff members involved in the incident may also be affected and should be fully supported by their line manager and the HR team.

Face-to-Face Meeting

A meeting should be offered and set up at the earliest convenience to discuss the incident and the issues involved. The resident / relative / carer may express a preference for which staff should attend the meeting.

Staff should introduce themselves and explain their role. An official, independent interpreter should attend if required. If the resident / relative / carer requires any support to deal with the consequences of the incident, information on where this support can be obtained should be provided.

Residents / relatives / carers should be advised who their information will be shared with and may raise objections to this. When information has to be shared to meet legal requirements, or disclosure is justified in the public interest, information may be shared without the resident’s consent.

Staff should consider that the resident/relative/carer might express anger or anxiety during the meeting and respond appropriately and professionally. In the event that the resident / relative / carer decline a meeting, this should be recorded.

Incident Investigation

An investigation into the cause of the incident must be conducted in accordance with the Safeguarding and Complaints procedures. This reflects that incidents usually result from system failures, rather than individual actions, and ensures that all possible contributory factors are identified and taken into account. The investigation should include the use of the Root Cause Analysis approach.

The manager must contact the resident (or next of kin) within 10 working days on completion of the investigation to offer to go through the outcome of the investigation, including any lessons identified. A copy of the investigation summary should be provided to the resident or next of kin.

Residents / relatives / carers should be given regular updates on the progress of the investigation either verbally / written / or by further meetings, adhering to the principles in previous stages of this procedure. Before information is provided to the resident / relatives / carers, this should be confirmed by an appropriate senior member of staff involved in the investigation.

The Senior Management team must approve investigation reports, before they can be shared with residents / relatives / carers.

The following guidelines should assist in making the communication effective:

  • The discussion should occur at the earliest practical opportunity, once there is additional information to report

  • Consideration should be given to the timing of the meeting/discussion, based on both the resident’s health and personal circumstances

  • Feedback should be given on progress to date and information provided on the investigation process

  • There should be no speculation or attribution of blame. Similarly, the professional communicating the incident must not criticise or comment on matters outside their own experience

  • The resident and / or their carers should be offered an opportunity to discuss the situation with another relevant professional where appropriate

  • A written record of the discussion should be kept and shared with the resident and/or their carers

  • All queries should be responded to appropriately

  • If completing the process at this point, the resident and/or their carers should be asked if they are satisfied with the investigation and a note of this made in the resident’s records

  • The resident should be provided with contact details so that if further issues arise later there is a conduit back to the relevant healthcare professionals or an agreed substitute.

Documentation

The communication of resident safety incidents must be recorded. Duty of Candour disclosures and meetings must be recorded in safeguarding reports with the time, place, and date as well as the name and relationships of all attendees and the outcome.

Required documentation includes:

  • incident reports

  • records of the investigation and analysis process

  • copies of all correspondence to the resident or next of kin

There should also be documentation of discussion meetings regarding the incident, including:

  • the time, place, and date, as well as the name and relationships of all attendees

  • the plan for providing further information to the resident and/or their carers

  • offers of assistance to the patients / family or carer

  • questions raised by the family and / or carers or their representatives and the answers given

  • plans for follow-up;

  • progress notes relating to the clinical situation and an accurate summary of all the points explained to the resident and / or their carers

  • copies of letters sent to residents, carers and the GP for resident safety incidents not occurring within primary care

  • copies of any statements taken in relation to the president safety incident

  • a copy of the incident report

Outcome, Feedback and Written Apology

These should be provided post-investigation.

Feedback on the Outcome of the Investigation

After completion of the incident investigation, feedback should take the form most acceptable to the resident, but in all cases put in writing. The manager must contact the resident / family or carer within 10 working days on completion of the investigation to offer to go through the outcome of the investigation, including any lessons identified. A copy of the investigation summary will be offered to the resident or next of kin.

The feedback must include:

  • The chronology of clinical and other relevant facts

  • Details of the resident’s and / or their carer’s concerns and complaints

  • A repeated meaningful apology for the harm suffered and any shortcomings in the delivery of care that led to the resident safety incident

  • A summary of the factors that contributed to the incident

  • Information on what has been, and will be, done to avoid recurrence of the incident and how these improvements will be monitored

  • It is expected that in most cases there will be a complete discussion of the findings of the investigation and analysis

  • In some cases, information may be withheld or restricted, for example: where communicating information will adversely affect the health of the resident; where investigations are pending coronial processes; where specific legal requirements preclude disclosure for specific purposes. In these cases, the resident will be informed of the reasons for the restrictions

  • The resident / relative / carer should be given the opportunity to respond to the outcome of the investigation, with any responses documented.

Not Satisfied with Outcome

Should the resident / relative / carer be not satisfied with the outcome, a mutually acceptable mediator should be arranged, to help identify areas of disagreement. Each point of disagreement should be addressed and a response provided in writing. The resident / relative / carer should also be informed about how to make a formal complaint, in accordance with the Complaints Procedure.

Special Circumstances / Exceptions

The approach to Duty of Candour may need to be modified according to the resident’s personal circumstances and the below should be taken into consideration.

At Another Organisation

In the event a resident safety incident has occurred in another organisation the individual who first identifies an earlier resident safety incident must notify the Safeguarding Team who will make arrangements to establish whether:

  • the resident safety incident has already been recognised;

  • the process of Being Open has commenced;

  • an incident investigation is underway.

Delayed Discovery of an Incident

On occasions, incidents become known as the result of a specific review or audit. Where this happens, it is important to look at the resulting investigation and the time that has elapsed since the initial incident. It is important to consider the impact the information may have on the resident’s family and / or carer and consider whether the policy still applies. A member of the Senior Management Team will make this decision.

Identifying Lessons and Communicating these

Identifying lessons
It is essential that any duty of candour investigation identifies lessons to minimise the possibility of recurrence of the events that led to harm. Action plans should be devised to manage these and the progress of these should be reported through the Safeguarding process. Lessons identified will be communicated during the discussion with residents / families / carers affected by the incident.

Communication of changes to staff
Effective communication with staff is a vital step in ensuring that recommended changes are fully implemented and monitored, and to increase awareness of resident safety and the value of Being Open. Team meetings, newsletters and the website are all available to help communicate with staff.

Responsibilities

The Principal – The Principal is ultimately responsible for ensuring the safety of residents, visitors and staff within the organisation. It is therefore the Principal’s responsibility to ensure that there are robust systems in place by which the principles of “Being Open” are implemented within the organisation. The Principal is
responsible for ensuring that this policy is implemented within all areas of the organisation through responsible Managers and representatives of the Safeguarding Team.

All Managers – All Managers are responsible for ensuring all staff are encouraged to report incidents; that all residents, their families, visitors, carers and others are communicated within a timely manner, with openness and honesty; and that all communication is documented.

All Staff – All staff involved in an incident resulting in long term injury or death need to understand the Being Open policy. A senior manager will support any staff involved in the Being Open process. All staff are required to complete in full and as directed any templates or proformas as instructed, for use as part of this policy.

Monitoring Compliance

Compliance against this policy will be overseen by Designated Safeguarding Lead. Additionally, all Root Cause Analysis investigations into Serious Incidents are checked by the Senior Management Team.

Review / Amendment

The organisation reserves the right to review this policy and procedure at any time if deemed necessary and to amend it accordingly. Any changes will be notified to all staff and updates uploaded to SharePoint and the College’s website.

Last Reviewed: May 2021
Person Responsible: Designated Safeguarding Lead