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CH35-Duty of Candour Policy

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Duty of Candour Policy

Policy Statement (Purpose and Definition)

This policy outlines the Duty of Candour as required by Regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The Duty of Candour is a legal obligation for all CQC-registered care providers to be open and transparent with people receiving care, especially when things go wrong. It exists to ensure honesty, trust, and transparency in adult social care, fostering a culture where patients, residents, and their families are promptly informed of incidents, receive apologies, and are supported. In essence, the Duty of Candour means that {{org_field_name}} and its staff will always communicate truthfully and compassionately with service users (and/or their representatives) about any unintended harm or mistakes in their care.

Scope

This policy applies to all staff and management of {{org_field_name}}, including care assistants, nurses, support staff, administrative staff, and the management team up to and including the Registered Manager ({{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}). Every person working in our care home has a responsibility to uphold the Duty of Candour in their day-to-day conduct. The statutory duty applies to all CQC-registered providers and registered managers (referred to as “registered persons”) in health and social care, meaning openness and transparency must be maintained at all times with people who use our service. The Registered Manager is responsible for ensuring this policy is implemented and that all staff understand their obligations under it.

Definitions

Duty of Candour: A general duty to be open and honest with people who use our service and their families/representatives when providing care, particularly when an incident occurs that causes harm. It requires us to inform individuals of certain incidents, apologize, explain what happened, and provide support, in a timely and transparent manner.

Notifiable Safety Incident: A specific term defined in Regulation 20 for an incident involving care that has caused (or could still cause) significant harm. An incident is “notifiable” if it meets ALL of the following criteria:

If any of the above three criteria are not met, the incident is not classified as a “notifiable safety incident” under this regulation. However, the general Duty of Candour still applies – staff must still be open and honest with the person about what happened even if the harm is less severe or the incident is not formally notifiable. In all cases, honesty and transparency are expected.

Relevant Person: The individual to whom the duty of candour is owed regarding an incident. In most cases this is the service user (resident) who was harmed. If the resident has died, lacks capacity, or is otherwise unable to fully understand/communicate, the relevant person would be someone lawfully acting on their behalf – such as a family member, legal guardian, or person with power of attorney. Communication under this policy will be directed to the relevant person as appropriate.

Roles and Responsibilities

Identifying Notifiable Safety Incidents

Staff must be vigilant in identifying incidents that may trigger the formal Duty of Candour procedure. Notifiable safety incidents are typically incidents that result in significant harm. Some examples in a care home setting may include (but are not limited to):

To qualify as notifiable, the incident must be unexpected/unintended and meet the harm thresholds described in Regulation 20. For example, if a resident slips because a care plan update was missed and breaks their arm, this is likely a notifiable incident: it occurred during care delivery and led to moderate harm (broken bone requiring treatment). In such cases, all Duty of Candour steps must be followed.

It is important to note that not every incident is notifiable. For instance, if a frail resident passes away from their long-term illness as expected, or if a minor bruise occurs despite proper care, these may not meet the Regulation 20 harm criteria. However, even in non-notifiable cases, staff should still explain to the person what happened and be honest (general candour). When in doubt about whether an incident is notifiable, staff should err on the side of transparency and consult a manager. The Registered Manager or a nurse may consult the Regulation 20 definitions or CQC guidance to determine if the threshold is met.

Procedure: Actions When a Notifiable Incident Occurs

If an incident qualifying as a notifiable safety incident is identified, the following procedure must be followed immediately (initiated “as soon as reasonably practicable” after the incident is discovered). Timeliness is critical – CQC expects prompt action with no undue delay. The Registered Manager (or delegated senior person on duty) will lead this process:

  1. Inform the Individual: Tell the affected person (or their representative) that the incident has occurred, and do so in person as soon as possible. This should be a face-to-face conversation, in private, with sensitivity. If the person has died or cannot comprehend, speak with their next-of-kin or representative. Begin by clearly but compassionately explaining that an incident has happened and outline what the incident was.
  2. Provide a Sincere Apology: Apologize to the person/representative for the harm or distress caused by the incident. This apology should be genuine and empathetic, acknowledging the suffering or adverse outcome. Crucially, apologizing is not an admission of legal fault or liability – it is the right thing to do morally and is required under the duty of candour. A timely, heartfelt apology can greatly help in maintaining trust.
  3. Explain the Facts (Known So Far): Provide an honest account of what happened, explaining the facts that are understood at that point in time. Be truthful and straightforward, avoiding jargon. If some details are not yet known (e.g. pending investigation), do not speculate or guess – just state what is known and that further information will be gathered. The individual has a right to know what happened and why (to the extent understood) in plain language.
  4. Outline Next Steps / Investigations: Inform the person about what will be done next to look into the incident. This may include conducting an internal investigation or review, arranging medical assessments, or taking actions to prevent further harm. Explain that the organization is taking it seriously and will investigate the causes. Also, let them know that they will be kept informed of findings or outcomes. If appropriate, also explain any immediate steps taken to care for the person’s health needs resulting from the incident.
  5. Provide Written Follow-Up: After the initial verbal notification and discussion, the care home must follow up in writing to the person or their representative. This written letter/email (sent in a timely manner, e.g. within a few days of the incident or as agreed with the person) will reiterate the apology, document the facts as known, and update on any actions or investigations underway. Providing this information in writing ensures there is a clear record and helps the person recall the details. It also demonstrates our transparency. A copy of this correspondence will be kept on file.
  6. Record Keeping: Maintain a written record of all communications and actions related to the Duty of Candour process. This includes notes of face-to-face meetings, telephone calls, copies of letters/emails, and any decisions or action plans made. These records must be kept securely (to maintain confidentiality) and should detail dates, times, attendees, and key points discussed. Good record-keeping provides evidence of compliance and is useful for learning lessons.

Throughout all these steps, the approach should be truthful, clear, and compassionate. The aim is to ensure the person harmed (or their family) fully understands what happened and what will be done to address it. Staff must avoid blaming individuals or making excuses – the focus is on facts and empathy, not defensiveness. The conversation is not about assigning blame; indeed, formal investigations may still be ongoing, and the priority at this stage is to communicate openly and caringly.

If the affected person has any questions or concerns during these communications, staff should answer to the best of their knowledge or promise to find out the answer if not known, and follow through on that. The individual should also be informed that they can involve a friend, family member, or advocate in these discussions if they wish.

Unable to Contact the Individual: In the rare event that the relevant person cannot be reached or refuses to engage in communication, the staff should document all attempts made to contact (dates, times, methods). Even if direct communication isn’t possible, the incident must still be internally reported and investigated, and notifications to regulators (like CQC, local authority, etc., if required) still made. The duty to be open is discharged by demonstrating you took reasonable steps to inform and apologize. All such instances should be reported to the Registered Manager, and a written record of the situation kept on file.

Providing Support to the Individual

Whenever an incident occurs, {{org_field_name}} will provide reasonable support to the person affected, as required under the duty of candour. This means we will consider the individual’s needs and do whatever is appropriate to help them cope with the incident’s effects and the candour process itself. Support may include:

Overall, our aim is to make sure the person (and their family) does not feel abandoned after an incident. We strive to be as accessible, responsive, and supportive as possible during what can be a difficult time. This supportive approach aligns with the spirit of candour – treating people with kindness, honesty, and respect.

Timeliness and Transparency in Communication

Timing: All communications under this policy must be carried out as promptly as possible. Regulation 20 requires that the Duty of Candour procedure is triggered “as soon as reasonably practicable” after a notifiable incident is identified. In practice, this means staff should not delay in reporting incidents to management, and the manager (or senior staff) should meet with the resident/representative at the earliest safe opportunity. Ideally, an initial apology and explanation are given within 24 hours of discovery of the incident (or sooner, if immediate awareness). Written follow-up should occur as soon as additional information is available, typically within a few days. The exact timing may depend on the person’s condition and availability, but unnecessary delays are not acceptable. Promptness demonstrates respect and maintains trust.

Transparency: All communication must be truthful and complete to the best of our knowledge. We will not hide facts or obfuscate. If we do not yet have certain information (for example, the full cause of the incident pending investigation), we will say so, and commit to informing the person once that information is known. Being transparent also means admitting when an error has occurred. We will clearly acknowledge when something was done incorrectly or an omission happened, and apologize for it. Under no circumstances should a staff member provide false or misleading information. If new information comes to light after the initial disclosure, the care home will update the person/representative accordingly in a timely manner.

We emphasize that being open and honest is a continuous obligation, not a one-time event. Even outside of specific incidents, all staff are expected to communicate openly about all aspects of care. Trust is built by consistent honesty. Additionally, management will ensure the person (or their family) is kept informed of investigation outcomes and any changes made to prevent recurrence, again in a timely and open way.

Apology and Open Communication Culture

Offering a sincere apology is at the heart of the Duty of Candour. Saying “sorry” promptly and genuinely is always the right thing to do when a person in our care has been harmed. The purpose of the apology is to acknowledge the harm and the person’s experience, and to express remorse that it happened. This apology must be given irrespective of fault – even if the incident was an accident or due to factors outside our control, we are still sorry that a person suffered harm. It is explicitly stated in guidance that apologizing is not an admission of liability. Staff should never be afraid to apologize due to fear of blame. In fact, failing to apologize can worsen the situation – many people are more upset by a lack of apology or honesty than by the error itself. A timely apology can help maintain a good relationship and may reduce the likelihood of complaints or legal action.

Our policy is that every notifiable incident warrants a verbal apology and a written apology to the affected party. The apology should be:

By embedding a culture of openness, staff are encouraged to speak up about mistakes and near-misses internally as well. We promote a “no blame” culture or just culture for reporting errors, meaning staff will not be punished for admitting mistakes that are made in good faith – instead, we focus on learning and improvement. This internal openness among staff supports the external candour with residents. Staff should feel confident that management will support them in doing the right thing by being honest with residents.

Documentation and Record-Keeping

Comprehensive documentation is essential for Duty of Candour compliance. For any notifiable safety incident, the following records must be maintained:

All these records will be kept confidentially in line with data protection, but be readily available for audit or in the event CQC or local authorities request evidence of our Duty of Candour compliance. The Registered Manager will periodically review incident files to ensure documentation is complete and up to date. Accurate records protect both the service user and our service by showing clearly what was communicated and done.

Additionally, certain incidents must still be notified to external bodies (like CQC notifications for serious injuries or local authority safeguarding, etc.) as required by other regulations. These notifications are separate from but related to the duty of candour. Fulfilling the duty of candour does not replace regulatory notifications – both must be done. Our incident reporting policy cross-references these requirements.

Staff Training and Awareness

Training: {{org_field_name}} is committed to training all staff on the Duty of Candour. All new employees will receive information about this policy and the principles of openness as part of their induction training. This includes understanding what the Duty of Candour is, what constitutes a notifiable incident, and how to respond. We will use real-life scenarios or case studies to illustrate the correct procedure (for example, discussing “what would you do if…?” situations). Care staff and nurses will undergo more detailed training on handling difficult conversations with residents and families, including role-playing how to apologize and communicate effectively after an incident.

We also provide refresher training or updates to staff, especially when there are changes in guidance or if an audit/incident review identifies learning points. At least annually (for example, during a staff meeting or an e-learning module) we will remind staff of their candour duties. Specific training sessions on communication skills, honesty in care, and ethical responsibilities will reinforce this. According to CQC expectations, providers should have appropriate training, policies, and systems in place to ensure staff can implement the Duty of Candour effectively.

The Registered Manager ({{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}) is responsible for ensuring training is completed and that candour is embedded in the company culture. This may involve highlighting the topic in supervision sessions or performance reviews, especially for managerial staff who might lead on candour communications.

Staff Support: We acknowledge that being open about mistakes can be challenging for staff. Therefore, management will support employees through the process. After a difficult incident, staff involved can debrief with a supervisor and will be guided on how to talk to the resident/family. If needed, the manager will directly handle the communication or be present to support the staff member. By creating an environment where staff feel safe to report errors, we empower them to fulfil their candour duties without fear. CQC expects providers to support their staff to be open and transparent when something goes wrong, as part of a positive safety culture. We strive to meet that expectation by treating reports of incidents as opportunities to learn, not occasions for unfair blame.

We also keep accessible resources about Duty of Candour (such as CQC’s own guidance summaries, “Being Open” leaflets, etc.) for staff to reference. Up-to-date copies of this policy are available to all staff, and key points may be posted on staff notice boards or included in newsletters.

Monitoring Compliance and Audit

Compliance with the Duty of Candour policy will be monitored through our internal governance processes:

Any breach of the Duty of Candour (failing to follow this policy when required) is considered a serious matter. Internally, it may result in disciplinary action, because it exposes residents to harm and the organization to legal risk. More importantly, it undermines the trust that is essential in care. Therefore, ensuring compliance is a top priority for management.

CQC Guidance and Regulatory Enforcement

This policy is written in line with CQC guidance on Regulation 20 (Duty of Candour) and the requirements of the fundamental standards. The Care Quality Commission treats candour as a fundamental standard “below which care must never fall”, meaning they pay special attention to this area during inspections. Inspectors may ask staff about their understanding of Duty of Candour, review our incident records, or interview families to confirm that we are open and honest when things go wrong.

Failure to comply with the Duty of Candour is a breach of Regulation 20 and is taken very seriously by CQC. Enforcement actions can be taken against the service provider or Registered Manager for breaches. According to CQC’s enforcement guidance, they have the power to issue warnings, requirement notices, impose conditions on our registration, or even prosecute for a criminal offense in serious cases. In fact, Regulation 20 explicitly allows CQC to move directly to criminal prosecution without first using civil enforcement, if a duty of candour breach is evident. The ultimate responsibility for carrying out the duty of candour lies with the “registered person” (our Registered Manager and/or the Provider). This means that CQC will hold our management accountable if the duty is not properly executed.

We are also aware that CQC expects evidence at registration and inspection that we understand and implement candour. For instance, during the provider registration process or manager interviews, we must demonstrate knowledge of candour obligations and show we have this policy, training, and systems in place. An open, honest culture is also reflected in our CQC ratings (e.g., it underpins the “well-led” and “safe” key questions).

Additionally, we reference external guidance such as the CQC’s own Duty of Candour guidance documents and the NHS “Saying Sorry” leaflet, which reaffirm that apologizing will not affect indemnity or litigation cover. By following best practice guidance, we aim to not only meet the letter of the law but also the spirit – which is to put residents first and be honest in all our dealings. Any updates CQC makes to their guidance (for example, clarifications on what is “unexpected or unintended” as updated in 2022) will be reviewed and this policy adjusted accordingly.

In summary, {{org_field_name}} will always strive to comply fully with Regulation 20. We view Duty of Candour not just as a regulatory checkbox, but as a core part of our values in delivering quality, person-centered care. By adhering to this policy, we ensure that our residents and their families can maintain trust in our service even when adverse events occur, and that we learn and improve from those events.

Review and Contact Information

This Duty of Candour Policy will be reviewed at least annually and whenever there are significant changes in relevant legislation or guidance. The Registered Manager ({{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}) is the owner of this policy and is responsible for its implementation. They will approve any revisions and ensure all staff are informed of updates.

Contact Information: For any questions about this policy or guidance on how to follow the Duty of Candour, staff should contact the Registered Manager. Phone: {{org_field_phone_no}}   Email: {{org_field_email}}. Additional resources or the latest version of this policy may also be available on our website ({{org_field_website}}).

Staff and managers should not hesitate to seek advice if unsure about any aspect of the Duty of Candour – it is crucial we get this right. By working together in an open and honest way, we continue to promote a safe environment and high-quality care for our residents, in line with both our ethical commitments and regulatory requirements.

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