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CH168-Open Door Policy

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Registration Number: {{org_field_registration_no}}

Open Door Policy

1. Purpose

The purpose of this policy is to establish a culture of openness, transparency, and approachability within {{org_field_name}}, where staff, volunteers, people we support, and their families feel comfortable to raise ideas, feedback, concerns, or complaints directly with managers and leadership. This policy supports compliance with Regulation 9 – Person-centred care, Regulation 10 – Dignity and respect, Regulation 13 – Safeguarding service users from abuse and improper treatment, Regulation 16 – Receiving and acting on complaints, Regulation 17 – Good governance, Regulation 20 – Duty of Candour, and the CQC assessment framework quality statements relating to learning culture, freedom to speak up, governance, partnership working and equity in access, experience and outcomes. It ensures that concerns are addressed early, feedback is valued, and everyone is heard without fear of dismissal or reprisal.

This policy does not replace the formal complaints, safeguarding, whistleblowing, grievance or disciplinary procedures. Where information received through an open door conversation meets the threshold for one of those procedures, the matter will be recorded, escalated and managed under the appropriate policy without delay.

2. Scope

This policy applies to all staff working within or on behalf of {{org_field_name}}, including care workers, administrative staff, agency workers, students, volunteers, and contractors. It also extends to the people we support, their relatives, representatives, advocates, and visitors. The policy ensures that all individuals, regardless of role or relationship with the service, have the opportunity to engage with the management team freely and safely.

This policy applies equally to people who may need additional support to raise a concern, including people living with dementia, people with a learning disability, autistic people, people with mental health needs, people with sensory impairment, people who use non-verbal communication, and people whose first language is not English. Reasonable adjustments will be made so that everyone has equal opportunity to speak with managers, share concerns, ask questions, make complaints or give feedback.

3. Related Policies

This policy should be read in conjunction with the following policies and procedures:

4. Statement of Commitment

{{org_field_name}} is committed to being a transparent, responsive, and people-led organisation. We believe that effective communication and early resolution of concerns leads to better relationships, higher staff morale, and improved quality of care. Our Open Door Policy means that any individual can approach a senior member of staff, including the Registered Manager or Deputy Manager, at any time to share feedback, ask questions, or raise issues. We treat all approaches with respect, confidentiality, and without judgement. Everyone will be listened to and responded to promptly and constructively.

{{org_field_name}} will not tolerate bullying, harassment, discrimination, victimisation, retaliation or any form of detriment against a person who raises a concern, gives feedback, makes a complaint, speaks up or supports someone else to do so. Any allegation of retaliation or intimidation will be investigated and may be managed under the disciplinary procedure, safeguarding procedure, whistleblowing procedure or other relevant process.

5. Implementation and Practice

The Registered Manager, {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}, ensures that management staff are accessible and visible across the service. Managers will remain accessible during working hours wherever reasonably practicable. The term “open door” refers to approachable and responsive leadership; it does not require office doors to remain physically open where this would compromise confidentiality, privacy, dignity, security, medicines safety, data protection, safeguarding, staff records or the comfort of the person raising the matter. Managers make regular visits to homes, attend handovers, and conduct check-ins with staff and people we support. Individuals are encouraged to raise matters directly, in person, by phone, via email, or through scheduled meetings. Where privacy is required, a private space is offered without delay to ensure the conversation is comfortable and confidential.

Where a person wishes to raise a matter privately, managers will offer a suitable private space and will ask whether the person needs any communication support, advocacy, translation, interpretation, accessible information, hearing support or other reasonable adjustment. Where the matter is urgent and a manager is not immediately available, the person receiving the concern must ensure it is escalated to the most senior person on duty without delay.

6. Encouraging Feedback from People We Support and Families

The people we support, and their families or representatives, are reminded regularly that they have the right to speak directly to senior staff about any matter. This includes care concerns, compliments, ideas, or anxieties. Posters displaying the names, photos, and contact details of the Registered Manager and Deputy Manager are placed in prominent areas, along with our feedback contact number {{org_field_phone_no}} and email {{org_field_email}}. Feedback forms are available in accessible formats and can be submitted anonymously if desired. We act on all feedback and ensure that the outcomes are communicated clearly to those who have shared their views.

Feedback will be actively sought in ways that reflect each person’s communication needs, preferences, capacity and circumstances. This may include one-to-one conversations, resident and relative meetings, surveys, easy read materials, large print, translated information, visual prompts, communication aids, advocacy support, best interests involvement where appropriate, and support from relatives or representatives where the person consents or where it is lawful and appropriate to involve them.

If feedback raises dissatisfaction about the care, treatment or support provided, staff must consider whether it should be handled as a complaint under CH14 – Receiving and Acting on Complaints Policy. A person does not need to use the word “complaint” for the matter to be treated as a complaint. Where the person wishes to make a formal complaint, or where the concern requires investigation, the complaints procedure must be followed.

People using the service and their relatives or representatives will be told how to contact the Registered Manager, the provider, the local authority safeguarding team, the Care Quality Commission and the Local Government and Social Care Ombudsman where relevant. Information about these routes will be displayed in the home and made available in accessible formats.

7. Supporting Staff Communication

All staff are encouraged to communicate freely and openly with their line managers and with senior leadership. During induction, staff are informed of their right to speak up and how to raise issues both informally and formally. Supervision sessions, team meetings, and daily handovers provide regular opportunities for discussion. Staff can also approach the Registered Manager directly without needing to go through their line manager. We actively promote a culture where questions, ideas, and respectful challenge are welcomed as part of reflective practice and service improvement.

Speaking up is not limited to care staff or permanent employees. Agency staff, bank staff, night staff, domestic staff, catering staff, maintenance staff, volunteers, students, contractors and visiting professionals are encouraged to raise concerns, ask questions and share ideas where they identify risks, poor practice, closed cultures, discrimination, abuse, neglect, unsafe care, poor staffing, poor communication or anything that may affect people’s safety, dignity, rights or wellbeing.

Staff may raise matters through their line manager, the Registered Manager, the nominated individual, the provider, the whistleblowing route, the safeguarding route, the local authority, CQC or another appropriate external body. Staff do not have to wait for supervision or a team meeting if the matter is urgent or relates to safety, abuse, neglect, poor practice or potential breach of regulation.

Managers will make reasonable adjustments to support staff to speak up, including staff who are disabled, neurodivergent, pregnant, experiencing mental health difficulties, have communication needs, are new to the service, work nights, work remotely from senior managers, or feel unable to raise concerns through normal line management arrangements.

8. Links to Whistleblowing and Safeguarding

The Open Door Policy complements but does not replace CH29 – Whistleblowing (Speaking Up) Policy or CH13 – Safeguarding Policy.

The following matters must not be treated as informal feedback only and must be escalated immediately under the appropriate procedure:

If a concern relates to abuse, unsafe practice, or unlawful conduct, it may also need to be reported under whistleblowing or safeguarding procedures. Staff are trained to recognise when concerns must be escalated further. No one will be treated unfairly for raising a genuine concern, even if it turns out to be mistaken. Anonymous reporting is also supported, and all concerns are treated seriously and followed up appropriately.

Where there is any doubt about whether a matter is safeguarding, whistleblowing, a complaint, a notifiable incident or a Duty of Candour event, the Registered Manager must seek advice from the provider, local safeguarding procedures, CQC guidance or other relevant professional advice and must take the safest and most transparent approach.

9. Handling and Responding to Open Door Conversations

When a person raises a concern, complaint, suggestion, compliment or question through the Open Door Policy, the member of staff receiving the information must:

Minor day-to-day matters may be resolved immediately where this is safe, appropriate and within the authority of the staff member or manager dealing with the issue. The action taken and outcome should be recorded where the matter may be relevant to care quality, safety, complaints, safeguarding, governance, staffing or future learning.

Where the matter cannot be resolved immediately, the Registered Manager or delegated senior person will decide the correct route for handling it. This may include informal resolution, complaint investigation, safeguarding referral, incident reporting, Duty of Candour process, whistleblowing process, staff grievance, disciplinary investigation, care plan review, risk assessment review or quality improvement action.

The person raising the matter will be updated in a timely and proportionate way, taking account of confidentiality, consent, data protection and safeguarding requirements. Where the matter is handled as a formal complaint, the timescales and process in the complaints policy will apply. Where the matter involves a safeguarding concern, local safeguarding procedures will apply.

All open door feedback that identifies a risk, pattern, recurring concern or opportunity for improvement will be reviewed as part of the service’s governance and quality assurance arrangements. Lessons learned will be shared with staff, people using the service and relatives or representatives where appropriate and lawful to do so.

10. Confidentiality, Consent and Information Sharing

Open door conversations will be treated sensitively and confidentially. Information will only be shared with those who need to know in order to respond, investigate, protect people, meet legal duties, improve care or comply with regulatory requirements.

Confidentiality cannot be guaranteed where the information suggests that a person is at risk of harm, a crime may have been committed, abuse or neglect may have occurred, a notifiable incident has taken place, a Duty of Candour requirement may apply, or the provider is legally required to share information with CQC, the local authority, the police, commissioners or another relevant body.

Where possible, the person raising the matter will be told what information needs to be shared, why it needs to be shared, who it will be shared with and what will happen next. Personal information will be handled in line with the Data Protection Act 2018, UK GDPR and the service’s confidentiality and records management policies.

11. Complaints and External Escalation

The Open Door Policy is intended to make it easier for people to speak with managers at an early stage, but it must not be used to avoid or delay the formal complaints process. Where a person is dissatisfied with their care, treatment, support, communication, environment, staff conduct, management response or any aspect of the service, they must be offered information about the complaints procedure.

A concern must be treated as a complaint where the person asks for it to be handled formally, where the concern requires investigation, where the person remains dissatisfied after initial discussion, or where the seriousness of the matter means informal handling would not be appropriate.

People using the service, relatives, representatives and advocates will be supported to raise complaints without fear of discrimination, withdrawal of care, poorer treatment or any negative consequence. Information about how to complain will be available in accessible formats and displayed clearly in the home.

Where a person remains dissatisfied with the provider’s response, they will be given information about how to contact the Local Government and Social Care Ombudsman, the local authority or commissioner where relevant. People may also share information about their experience of care with CQC at any time, although CQC does not investigate individual complaints in the same way as the provider or Ombudsman.

12. Duty of Candour

Where an open door conversation identifies that a notifiable safety incident may have occurred, the Registered Manager must ensure that the Duty of Candour Policy is followed. This includes acting in an open and transparent way, providing a truthful account of what is known at the time, offering an apology, explaining what further enquiries will take place, keeping the relevant person informed, and keeping a written record of the process.

Staff must immediately report any incident, concern or information that may indicate avoidable harm, significant harm, prolonged psychological harm, abuse, neglect or unsafe care. Managers must consider whether the matter requires notification to CQC, safeguarding referral, commissioner notification, incident investigation, complaint investigation, police involvement or other external reporting.

13. Promoting a Culture of Openness

We promote our Open Door Policy as part of everyday culture at {{org_field_name}}. It is referenced in training, embedded in staff handbooks, and reinforced through leadership behaviour. Senior leaders lead by example, demonstrating openness, humility, and approachability. The organisation values staff and service user voice as essential to our quality improvement processes. We do not tolerate intimidation, bullying, or reprisals in response to individuals speaking up and take action against any behaviour that undermines this culture.

The service will actively guard against closed cultures by encouraging challenge, listening to people who may be less able or less confident to speak up, reviewing themes from complaints and feedback, and acting promptly where people, relatives, staff or professionals say they do not feel listened to. Leaders will promote psychological safety, equality, inclusion and learning so that speaking up is seen as a normal and valued part of improving care.

14. Monitoring and Evaluation

The Registered Manager will monitor the effectiveness of this policy through the service’s governance and quality assurance systems. This will include reviewing:

The Registered Manager will review themes at regular governance meetings and will ensure that actions are allocated, followed up and completed. Where feedback identifies a risk to people’s safety, dignity, rights, wellbeing or quality of care, action must be taken without delay.

Learning from feedback will be shared with staff and, where appropriate, with people using the service, relatives, representatives, advocates, commissioners and other stakeholders. The service will use feedback to improve practice, update policies, review training needs, strengthen staffing arrangements and improve the experience of people living in the home.

15. Staff Training and Awareness

All staff will be made aware of this policy during induction and through ongoing supervision, team meetings, training and communication from managers. Staff will be expected to understand:

Managers will ensure that staff understand that listening and responding to feedback is part of their duty to provide safe, person-centred and respectful care.

16. Policy Review

This policy will be reviewed at least annually, or earlier where required due to changes in legislation, statutory guidance, CQC guidance, CQC assessment findings, safeguarding learning, complaints trends, whistleblowing concerns, serious incidents, Duty of Candour events, organisational change or identified gaps in practice.

The review will include feedback from staff, people using the service, relatives, representatives and advocates where appropriate. The Registered Manager will ensure that the policy remains practical, accessible, legally compliant and aligned with current CQC expectations for safe, effective, caring, responsive and well-led services.

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}}
Copyright © {{current_year}} – {{org_field_name}}. All rights reserved.

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