{{org_field_logo}}

{{org_field_name}}

Registration Number: {{org_field_registration_no}}

---

Open Door Policy

1. Purpose

The purpose of this policy is to establish a transparent, accessible, and inclusive environment at {{org_field_name}} where individuals using our service, their families, staff, professionals, and visitors feel welcome to communicate openly with the management team. This Open Door Policy encourages honest dialogue, early resolution of concerns, a culture of mutual respect, and continuous improvement in line with the Regulation and Inspection of Social Care (Wales) Act 2016 and CIW’s core principles of openness, accountability, and person-centred care. The policy is also aligned with the Social Services and Well-being (Wales) Act 2014 which emphasises voice, choice, and control for individuals receiving care.

2. Scope

This policy applies to everyone who interacts with {{org_field_name}}. It is relevant to residents, relatives, friends, visiting professionals, staff at all levels, contractors, volunteers, and CIW inspectors. It also guides the conduct and responsibilities of the Registered Manager, Responsible Individual, senior carers, and team leaders in maintaining an open and approachable leadership culture.

3. Related Policies

This policy should be read in conjunction with:
CHW04 – Good Governance
CHW07 – Person-Centred Care Policy
CHW08 – Dignity and Respect Policy
CHW14 – Receiving and Acting on Complaints Policy
CHW27 – Staff Supervision, Training, and Development Policy
CHW29 – Whistleblowing (Speaking Up) Policy
CHW35 – Duty of Candour Policy
CHW42 – Communication and Engagement with Service Users and Families Policy

4. Policy Statement and Procedures

4.1 Promoting Accessibility and Approachability

At {{org_field_name}}, the Registered Manager, {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}, and all members of the senior team maintain an open-door approach during working hours. This means that individuals can approach them freely, without an appointment, to discuss any matter of importance. A sign indicating the availability of the Registered Manager is placed outside their office. If the manager is unavailable, a senior member of staff is always designated to receive queries or concerns. We make it clear through induction, noticeboards, and conversations that there are no barriers to communication and that every voice matters.

4.2 Creating a Culture of Openness and Trust

This policy is not only about physical accessibility to the office but about fostering a psychologically safe and welcoming culture. Staff are encouraged to speak openly about their ideas, suggestions, or concerns without fear of retribution. Similarly, individuals using the service and their families are regularly reminded that they have a right to raise any matter with management at any time. We promote open dialogue through regular resident and relatives’ meetings, staff meetings, suggestion boxes, and informal feedback opportunities. Our management team leads by example in being visible, compassionate, and responsive.

4.3 Early Identification and Resolution of Issues

By maintaining an open-door approach, we aim to identify and resolve concerns before they escalate into complaints. All team leaders and care staff are trained to listen actively and escalate any issue to the appropriate person without delay. When someone brings an issue forward, we acknowledge it, listen fully, and either resolve it on the spot or agree on a follow-up time. Records are kept of the concern and actions taken, in accordance with CHW14 – Receiving and Acting on Complaints Policy and CHW35 – Duty of Candour Policy where required.

4.4 Empowering Individuals Using Our Service

Individuals in our care are given frequent reassurance that they can speak to any member of staff about anything that is bothering them, and that their comments will be taken seriously. For residents with communication difficulties, visual aids, talking mats, and support from key workers or advocates are used to ensure they are heard. We regularly ask open-ended questions during care planning and reviews to encourage feedback. All efforts are made to ensure residents feel confident and safe to express preferences or raise concerns, particularly in one-to-one settings.

4.5 Supporting Staff to Use the Open Door Policy

All staff are trained during induction and ongoing development to understand the importance of open communication. The Open Door Policy is reinforced during supervision sessions, team meetings, and through daily practice. Staff are reminded that they can speak to the Registered Manager or Responsible Individual about anything affecting their wellbeing, performance, morale, or the quality of care being provided. Staff may also be accompanied by a colleague if they wish to raise a sensitive issue, and we support a no-blame culture that encourages reflective practice and learning.

4.6 Integration with Safeguarding, Whistleblowing and Other Formal Procedures

The Open Door Policy provides an additional route for individuals, representatives, staff, volunteers and others to raise matters with the management team. It does not replace, delay or prevent the use of the service’s safeguarding, complaints, whistleblowing, incident reporting, duty of candour or regulatory notification procedures where these apply.

Where information received under this policy gives rise to an allegation, evidence or reasonable concern that an individual may be experiencing or be at risk of abuse, neglect or improper treatment, staff must act immediately in accordance with the service’s Safeguarding Policy and the Wales Safeguarding Procedures. The immediate safety and well-being of the individual and any other person who may be at risk must be protected. The concern must be reported without delay to the appropriate manager or safeguarding lead and appropriate referrals must be made to the relevant local authority safeguarding service and any other statutory agency as required. Where the circumstances require police involvement or another emergency response, this must not be delayed while internal reporting takes place.

A record must be made of the allegation, evidence or concern received, the immediate action taken to protect individuals, all referrals made and any subsequent action or outcome. Where the event is notifiable to Care Inspectorate Wales or another statutory body, the required notification must be made in accordance with the applicable legislation and the service’s notification procedures.

Where a person working at or for the service raises a concern about malpractice, wrongdoing, illegality, unsafe practice or another matter that may adversely affect the health, safety or well-being of individuals, the matter must be considered under CHW29 – Whistleblowing (Speaking Up) Policy where appropriate. Whistleblowing concerns must be investigated, appropriate action must be taken following the investigation and a record must be maintained.

Staff and volunteers must be supported to raise genuine concerns and must not be subjected to victimisation, harassment or disadvantage for doing so. Nothing in this policy prevents a worker from making a qualifying disclosure directly to Care Inspectorate Wales or another prescribed person or body where permitted by law.

Where a concern indicates that something has gone wrong in the provision of care and support, the requirements of CHW35 – Duty of Candour Policy must also be considered and followed where applicable.

4.7 Recording, Responding to and Reviewing Concerns Raised Informally

Concerns raised through the Open Door Policy must be acknowledged, considered and recorded in a manner proportionate to their nature and seriousness. The fact that a person raises a matter informally does not remove the requirement to use a formal procedure where the nature of the concern requires this.

The member of staff receiving the concern must establish, so far as reasonably practicable, what the person is raising and what outcome they are seeking. Where the matter constitutes, or the person wishes it to be treated as, a complaint, it must be managed in accordance with CHW14 – Receiving and Acting on Complaints Policy. A person must not be prevented or discouraged from making a formal complaint because an informal resolution has been offered.

Where information indicates a safeguarding concern, whistleblowing concern, significant incident, possible breach of the duty of candour or an event requiring notification to Care Inspectorate Wales or another statutory body, the relevant formal procedure must be commenced without delay. Informal resolution must never be used as a substitute for a statutory referral, investigation or notification.

An appropriate record must be maintained showing:

• the date the concern was raised;
• the nature of the concern;
• the person raising it, unless the matter was raised anonymously;
• any immediate action taken;
• whether the matter was referred into another procedure, including complaints, safeguarding, whistleblowing, incident reporting or duty of candour;
• any referrals or regulatory notifications made;
• the person responsible for follow-up;
• the action taken and outcome, where known; and
• any learning or improvement identified.

Information must be recorded accurately and stored securely in accordance with the service’s record-keeping and data protection arrangements. Information must only be shared where there is a lawful and appropriate reason to do so.

The Registered Manager must ensure concerns and feedback are reviewed regularly so that recurring themes, patterns, risks or potential service failures are identified and acted upon. Relevant information about concerns, complaints, safeguarding matters, whistleblowing and incidents must be made available to the Responsible Individual so that it can inform oversight of the service and the review of the quality of care and support required by the Regulations.

Where reasonably practicable and appropriate, the person who raised the concern must be informed of the action or outcome, subject to confidentiality, safeguarding, employment and data protection requirements.

4.8 Communication and Promotion of the Policy

This policy is shared with new staff at induction and highlighted in the Staff Handbook. Individuals and families are informed of the Open Door Policy upon admission and through welcome packs, noticeboards, care planning conversations, and newsletters. We encourage all visitors to raise concerns directly and to feel reassured that they are welcomed and respected. Translators, advocates, and support tools are made available for individuals with specific communication needs. This approach supports our commitment to accessibility, equity, and inclusion.

4.9 Supporting CIW Inspections and External Visitors

During CIW inspections, we maintain full openness with inspectors. The Registered Manager makes themselves available to answer questions, provide documents, and facilitate access to staff and residents. Inspectors are encouraged to speak with anyone they wish, and any queries raised during inspection are followed up promptly. The Open Door Policy reassures CIW that we are continuously listening, learning, and improving based on feedback and lived experience.

5. Policy Review

This policy will be reviewed at least annually and sooner where required to ensure that it remains current, effective and consistent with the service’s Statement of Purpose.

An earlier review must be undertaken where relevant following:

• a change to legislation, regulations, statutory guidance or applicable regulatory requirements;
• a change to the service’s Statement of Purpose which affects this policy;
• relevant guidance or requirements issued by Care Inspectorate Wales, Welsh Government or Social Care Wales;
• learning arising from complaints, concerns, safeguarding matters, whistleblowing, incidents or duty of candour matters;
• findings arising from Care Inspectorate Wales inspection or other regulatory activity;
• findings from the Responsible Individual’s oversight, visits or review of the quality of care and support;
• an identified failure or weakness in the operation of this policy; or
• a significant change to the way the service is managed or provided.

Where amendments to this policy directly affect individuals using the service or their representatives, the changes will be communicated to them in a timely and accessible manner. Staff and volunteers will be informed of relevant amendments and will be provided with any information, instruction or training required to understand and implement the revised policy.

The Responsible Individual will maintain suitable arrangements to ensure that this policy is kept up to date and that staff and volunteers have access to, and understand, the policy insofar as it relates to their roles.

---

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.