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Registration Number: {{org_field_registration_no}}

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Duty of Candour Policy

1. Purpose

The purpose of this policy is to ensure that {{org_field_name}} meets the statutory duty of candour by acting in an open and transparent way with individuals receiving care and support and any representatives (and, where applicable, a placing authority), and by promoting a culture of openness, honesty and learning when things go wrong.

The Duty of Candour requires care providers to be honest with service users, their families, and regulatory bodies when things go wrong, particularly in cases involving:

• Errors or incidents that have caused or could cause harm.
• Failures in care that impact service user safety or well-being.
• Mistakes in service delivery, medication administration, or safeguarding.

By implementing a robust Duty of Candour policy, {{org_field_name}} ensures:

• All staff understand their legal and ethical responsibilities to be open and transparent.
• Service users and families receive timely and honest explanations when things go wrong.
• CIW and other relevant agencies are notified of significant incidents in accordance with regulations.
• Incidents are investigated thoroughly and used as learning opportunities to improve care quality.

2. Scope

This policy applies to:

• All employees, including care staff, administrative personnel, and management.
• The Registered Manager and Responsible Individual, responsible for ensuring compliance with Duty of Candour obligations.
• Service users, their families, and representatives, who have the right to receive full disclosure when care issues occur.
• External regulatory bodies, such as CIW and Local Authority Safeguarding Teams, where reporting is required.

3. Legal and Regulatory Framework

This policy aligns with the following laws and regulations:

• The Regulation and Inspection of Social Care (Wales) Act 2016, which mandates transparency and openness in care services​.
• The Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, which require care providers to report significant incidents and maintain records of disclosures​.
• The Social Services and Well-being (Wales) Act 2014, which enforces safeguarding duties, requiring care providers to report harm and near misses.
• The duty of candour requirements for regulated social care services are set out in the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017 (as amended), including:

• Regulation 13 (Service provider duty of candour) – acting in an open and transparent way with individuals receiving care and support and any representatives (and, where applicable, the placing authority).
• Regulation 83 (Responsible individual duty of candour) – the responsible individual must act in an open and transparent way and ensure suitable arrangements are in place to secure compliance.
• Notifications requirements for service providers and responsible individuals, including the relevant Schedules (for example Schedule 3 / Schedule 4, as applicable), and the requirement for notifications to be made without delay and in the manner required by CIW.
• Social Care Wales professional duty of candour guidance for staff who are professionally registered, and our arrangements for responding to potential breaches (including, where appropriate, referral to the professional regulator).
• The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) 2013, which mandates reporting of serious incidents to the Health and Safety Executive (HSE).

4. Principles of the Duty of Candour

The Duty of Candour requires staff to:

• Be open and honest when an error, harm, or significant incident occurs.
• Apologise and explain what happened, in a way that service users and families can understand.
• Take immediate action to prevent further harm.
• Investigate incidents thoroughly and identify lessons learned.
• Ensure records of all disclosures and actions taken are maintained.
• Provide individuals and/or their representatives with information about what happened and the outcome of any investigation, including any learning and improvements made.
• Take action to prevent and appropriately address bullying, victimisation and/or harassment linked to speaking up or exercising the duty of candour, and investigate any concerns that any person (including a manager/RI) may have obstructed another from being candid.
• Where a member of staff is professionally registered, apply our process to identify and respond to any possible breach of the professional duty of candour, including (where appropriate) escalation through HR/disciplinary processes and referral to the relevant professional regulator (for example Social Care Wales).

How we manage this efficiently:

• All staff receive Duty of Candour training, ensuring they know when and how to disclose incidents.
• An internal reporting system is in place, allowing staff to log and track disclosures.
• Managers oversee compliance, ensuring all incidents are properly recorded and acted upon.

5. Implementing the Duty of Candour in Practice

5.1 Identifying Incidents Requiring Disclosure

The Duty of Candour applies when:

• A service user experiences harm due to an error, accident, or failure in care.
• A near miss occurs, meaning a potential risk was identified before harm was caused.
• There is a safeguarding issue that requires reporting.
• Incorrect medication is given, resulting in possible harm.
• There is a failure to follow a service user’s care plan, leading to negative consequences.

5.2 Notifying Service Users and Families

When an incident occurs:

1. Immediate action is taken to ensure the service user’s safety and well-being.
2. The incident is recorded in detail, including time, date, people involved, and actions taken.
3. The Registered Manager or senior staff member contacts the service user and their family as soon as possible, providing:
   • A clear and honest explanation of what happened.
   • A formal apology acknowledging the error.
   • Details of steps being taken to prevent recurrence.
4. The discussion is documented, and a copy of the report is given to the service user or their family upon request.

How we manage this efficiently:

• Communication templates help staff provide clear and consistent disclosures.
• A duty of candour checklist guides staff through the notification process.
• Family meetings are arranged if necessary, to discuss concerns in a supportive setting.

5.3 Reporting Incidents to CIW and Other Agencies

Notifications to CIW (service regulator) will be made in line with the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017 (as amended), including the relevant notification schedules for the service/provider (for example Schedule 3 / Schedule 4, as applicable). Notifications will be made without delay, usually within 24 hours of the event occurring unless the Regulations specify otherwise, and will be submitted in writing using CIW Online (or in another manner required by CIW).

Examples of notifiable events include those set out in the relevant notification schedules (for example abuse/allegation of abuse, serious accident or injury, outbreak of infectious disease, incidents reported to the police, events that could prevent safe service delivery, and other events specified for the service type).

How we manage this efficiently:

• Incident reporting forms are pre-filled where possible, reducing delays in notifications.
• Staff are trained in when and how to report incidents to regulatory bodies.
• Senior managers review all reports before submission to ensure accuracy and completeness.

6. Learning from Incidents

A key part of the Duty of Candour is ensuring that incidents lead to meaningful improvements in service quality.

6.1 Investigating the Cause

Following an incident:

1. A lead investigator is assigned to gather evidence, interview staff, and review policies.
2. A formal investigation report will be completed as soon as practicable (our usual aim is within 10 working days). Where this is not achievable, we will record the reasons, agree revised timescales, and provide the individual and/or their representative with appropriate interim updates and the outcome once concluded.
3. Findings are shared with staff, service users, and CIW where necessary.

6.2 Implementing Corrective Actions

Actions may include:

• Updating staff training to prevent similar errors.
• Revising policies and procedures to address gaps in practice.
• Providing additional supervision to improve compliance with best practices.

How we manage this efficiently:

• Regular case reviews identify recurring issues, allowing for targeted improvements.
• Lessons learned are shared through staff training and internal newsletters.
• Feedback is sought from service users, ensuring corrective actions meet their needs.

7. Supporting Staff During the Duty of Candour Process

It is essential that staff feel supported when reporting incidents and disclosing errors.

• Managers provide reassurance to staff involved in an incident.
• Emotional and professional support is offered, including debriefing sessions.
• Staff are encouraged to report concerns without fear of blame or punishment.
• Whistleblowing protections apply if a staff member raises concerns about failure to comply with the Duty of Candour​.

How we manage this efficiently:

• A confidential reporting system allows staff to raise concerns anonymously.
• A Just Culture approach focuses on learning from mistakes, rather than assigning blame.

7.1 Preventing obstruction and responding to professional duty of candour concerns

{{org_field_name}} operates a zero-tolerance approach to any behaviour that discourages openness, including bullying, victimisation, harassment or any attempt to obstruct a member of staff from being candid with an individual, their representative, or the organisation. Any concerns of obstruction will be investigated and addressed through supervision, HR and/or disciplinary processes as appropriate.

Where the concern relates to a person who is professionally registered (for example with Social Care Wales), the Registered Manager/Responsible Individual will ensure there is a clear process to identify and respond to possible breaches of the professional duty of candour. This includes taking proportionate management action and, where appropriate, making a referral to the relevant professional regulator or other relevant body.

8. Related Policies

This policy aligns with:

• Safeguarding Adults Policy (DCW13)​.
• Notification of Other Incidents Policy (DCW25)​.
• Risk Management and Assessment Policy (DCW18)​.
• Whistleblowing (Speaking Up) Policy (DCW29)​.

9. Policy Review

This policy will be reviewed annually or sooner if required due to changes in legislation, business needs, or CIW regulations. The Registered Manager and Responsible Individual are responsible for ensuring its accuracy and implementation.

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Responsible Person: {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}
Reviewed on: {{last_update_date}}
Next Review Date: {{next_review_date}}
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