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{{org_field_name}}

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}} acts in an open, honest and transparent way with individuals receiving care and support, their representatives and, where relevant, placing authorities, whenever concerns arise or things go wrong in connection with the service.

For the purposes of this policy, duty of candour means creating and maintaining a culture in which staff, managers, the Responsible Individual and the service provider are expected to be open and honest at all times, and especially when a mistake, omission, incident, near miss, safeguarding concern, complaint, or service failure has occurred. This includes telling people what has happened, apologising where appropriate, explaining what is known, explaining what will happen next, keeping accurate records, making referrals and notifications where required, and learning from events to improve the service.

This policy is intended to support compliance with:

• Regulation 13 of the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017 (Duty of Candour);
• Regulation 83 of the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017 (Duty of Candour of the Responsible Individual);
• the Regulation and Inspection of Social Care (Wales) Act 2016 and the Welsh Government statutory guidance for care home and domiciliary support services, Version 3, March 2024;
• the Social Services and Well-being (Wales) Act 2014;
• the Social Care Wales Code of Professional Practice for Social Care Workers, the Code of Practice for Social Care Employers, and Social Care Wales explanatory guidance on the professional duty of candour.

This policy applies to the delivery of regulated social care services in Wales. It is separate from the organisational duty of candour which applies to NHS bodies in Wales, unless {{org_field_name}} is carrying out functions to which that NHS duty specifically applies.

2. Scope

This policy applies to:

• the service provider;
• the Responsible Individual;
• the Registered Manager;
• all employees, workers, bank staff, agency staff, students and volunteers working at or for {{org_field_name}};
• all individuals receiving care and support from the service;
• representatives, advocates and, where applicable, placing authorities and commissioners.

Duty of candour is relevant whenever there is a concern, event or practice issue that affects, or could affect, the quality, safety, dignity, rights or well-being of an individual. This includes, but is not limited to:

• mistakes, omissions, missed care or delays in care;
• medication errors or medicine-related concerns;
• accidents, injuries, falls and pressure damage;
• safeguarding concerns, allegations of abuse, neglect or improper treatment;
• incidents involving control, restraint or restrictive practice;
• communication failures, record-keeping failures or consent/capacity failures;
• complaints, concerns raised by families, advocates or staff;
• near misses and events that did not result in harm but could have done;
• any event requiring notification to CIW or referral to other agencies.

{{org_field_name}} will not apply an artificially narrow threshold before being open and honest. The response will be proportionate to the circumstances, but openness and honesty are expected at all times.

3. Principles of the Duty of Candour

3.1. Commitment to Openness and Honesty

{{org_field_name}} is committed to a culture of openness, honesty, transparency, respect and learning. This means that the service provider, the Responsible Individual, the Registered Manager and all staff must act in an open and transparent way with individuals receiving care and support and their representatives.

We will:

• encourage staff to raise concerns, admit mistakes and report incidents without concealment;
• promote a fair and learning culture, while still taking appropriate action where misconduct, recklessness, abuse, obstruction, victimisation or repeated poor practice is identified;
• ensure candour is practised in a way that protects the individual’s rights, dignity, voice, privacy and well-being;
• provide information in a format, language and manner the individual can understand, including taking account of communication needs, Welsh language needs, capacity and advocacy needs;
• ensure that openness with individuals is matched by openness within the organisation, including prompt escalation to managers, the Responsible Individual and external agencies where required.

3.2 Immediate Reporting, Escalation and Notification

All staff must report any incident, concern, complaint, mistake, omission, near miss, safeguarding issue or service failure immediately, or as soon as reasonably practicable, to the senior person on duty and the Registered Manager in accordance with the service’s incident reporting, safeguarding and complaints procedures.

Reporting must include:

• a clear factual account of what has happened or is suspected to have happened;
• the date, time, place, people involved and immediate action taken;
• whether the individual is safe and whether urgent medical attention is required;
• whether family, representative, advocate, commissioner or placing authority has been informed;
• whether the matter may require safeguarding referral, police involvement, professional regulator referral or CIW notification.

The Registered Manager must ensure, without delay, that:

• immediate steps are taken to protect the individual and anyone else at risk;
• any necessary medical assistance is obtained;
• any safeguarding referral is made in line with Wales Safeguarding Procedures and local arrangements;
• records are completed promptly, accurately and contemporaneously;
• relevant evidence is preserved;
• the Responsible Individual is informed promptly of significant incidents and risks;
• CIW is notified where an event falls within the notification requirements for the service.

Notifiable events must be submitted in the manner required by CIW, normally via CIW Online, within the required timescale. The service will have clear internal responsibility for drafting, checking and submitting notifications, and for retaining evidence of submission.

For avoidance of doubt, the duty of candour applies alongside, and does not replace, requirements under safeguarding, complaints, incident reporting, health and safety, medicines, records management, notifications and whistleblowing procedures.

3.3 Informing Individuals, Representatives and Others

When something goes wrong, or may have gone wrong, {{org_field_name}} will be open and honest with the individual receiving care and support and, where appropriate, their representative, advocate, commissioner or placing authority.

This will include:

• explaining what has happened, or what is currently known;
• explaining what immediate action has been taken to keep the person safe;
• offering a sincere apology where appropriate;
• explaining what will be investigated, by whom, and what will happen next;
• explaining whether referrals or notifications have been made to external bodies;
• keeping the individual and/or their representative updated as new information becomes available;
• providing information in an accessible format and in a way the person can understand;
• offering support, including advocacy, emotional support, practical support and access to the complaints process.

Where the individual has substantial difficulty in understanding or participating, or lacks capacity to make a relevant decision, the service will act in accordance with the Mental Capacity Act 2005, involve any lawful representative, and consider whether advocacy support is required.

A written summary of the discussion, apology, actions and next steps will be offered and a record will be kept on the individual’s file and the service’s incident/complaint/safeguarding records as appropriate.

3.4 Investigation, Outcome and Learning

Every reported incident or concern will be reviewed and investigated in a way that is proportionate to the seriousness, complexity and level of risk involved.

Investigations will:

• establish the facts as far as possible;
• identify immediate and underlying causes or contributing factors;
• consider whether the individual’s personal plan, risk assessments, staffing, communication, training, supervision, equipment, environment or management arrangements contributed to the event;
• identify whether misconduct, abuse, neglect, improper treatment, poor professional practice or a systems failure may have occurred;
• identify what action is needed to reduce the risk of recurrence.

The outcome of the investigation will be recorded and, where appropriate, shared with the individual and/or their representative in an open and timely way. Action may include:

• review of the personal plan or risk assessment;
• referral for medical or specialist advice;
• safeguarding action;
• notification to CIW or another authority;
• training, supervision, competency review or increased oversight;
• disciplinary action;
• referral to Social Care Wales, the DBS, the police or another professional/regulatory body where appropriate;
• service-wide changes to policy, procedure or practice.

Where significant or recurring concerns are identified, the Registered Manager and Responsible Individual will ensure the issue is escalated through governance, quality assurance and service improvement arrangements.

3.5. Protecting and Supporting Whistleblowers

Staff who raise concerns about unsafe practices, errors, or unethical conduct will be:

• Fully protected under our Whistleblowing (Speaking Up) Policy.
• Encouraged to report concerns without fear of retaliation.
• Provided with additional support, including access to external whistleblowing agencies if necessary​.

Raising a concern under this policy, through incident reporting, complaints handling, safeguarding or whistleblowing routes, must never lead to bullying, victimisation or harassment. Any concern that a person has been discouraged, silenced, intimidated or treated unfairly for speaking up will be taken seriously, investigated promptly and managed under the appropriate disciplinary, grievance, safeguarding or governance process.

3.6 Preventing Obstruction and Addressing Breaches of Candour

{{org_field_name}} will not tolerate concealment, falsification of records, misleading accounts, delayed escalation, intimidation, victimisation, harassment or any other act that prevents a person from being open and honest.

The service will:

• take action to prevent bullying, victimisation or harassment linked to candour or speaking up;
• investigate any concern that a board member, Responsible Individual, manager, member of staff or volunteer has obstructed another person in exercising candour;
• treat deliberate concealment, dishonest recording, failure to escalate serious concerns, or retaliation against a person who has raised a concern as a serious matter;
• consider disciplinary action and, where appropriate, referral to CIW, Social Care Wales, the DBS, the police or another relevant body;
• maintain systems to identify possible breaches of professional duty of candour by registered professionals and deal with such matters promptly and fairly.

4. Managing the Duty of Candour Efficiently

4.1. Training and Awareness

All staff, including agency staff and volunteers as appropriate to their role, will receive information, instruction and training on duty of candour as part of induction and through refresher training thereafter.

Training will cover:

• what duty of candour means in regulated social care services in Wales;
• prompt reporting and escalation requirements;
• how to speak openly and compassionately with individuals and families;
• apology, explanation and ongoing communication;
• record keeping and preserving factual accuracy;
• links with safeguarding, complaints, incident reporting and notifications;
• Mental Capacity Act 2005, advocacy and accessible communication;
• Welsh language and communication needs where relevant;
• recognising and reporting obstruction, concealment, bullying, victimisation or retaliation.

Managers and senior staff will receive additional training on leading investigations, making notifications and referrals, and evidencing learning and quality improvement.

4.2. Leadership and Accountability

The service provider, the Responsible Individual and the Registered Manager share responsibility for ensuring the service operates in an open and transparent way.

The Registered Manager is responsible for day-to-day implementation of this policy, including:

• ensuring incidents and concerns are responded to promptly;
• ensuring records are accurate and complete;
• ensuring people are informed openly and appropriately;
• ensuring staff receive support, supervision and training;
• ensuring referrals and notifications are made where required.

The Responsible Individual is responsible for oversight and assurance that duty of candour arrangements are effective in practice, including:

• monitoring whether the service is acting openly and transparently;
• reviewing themes, incidents, complaints, safeguarding matters and learning;
• ensuring the provider’s whistleblowing arrangements are effective;
• ensuring the service’s governance systems identify where quality or safety may be compromised and respond without delay.

4.3 Monitoring, Governance and Continuous Improvement

Duty of candour will be monitored through the service’s governance and quality assurance systems. This will include regular review of:

• incidents, accidents, injuries and near misses;
• complaints and compliments;
• safeguarding referrals and outcomes;
• medication errors;
• pressure damage and falls;
• use of control, restraint or restrictive practice;
• staff concerns and whistleblowing matters;
• CIW notifications and any learning arising from them;
• audit findings, supervision themes and training compliance.

Themes and trends will be analysed to identify learning, required actions and service improvements. Learning will be shared with staff and, where appropriate, individuals and representatives. The Responsible Individual will use this information to inform oversight of the service and relevant quality of care reviews.

5. Supporting Individuals and Their Representatives

When an incident, mistake, omission, complaint or service failure affects an individual, {{org_field_name}} will provide support that is person-centred, compassionate and accessible.

This will include:

• offering a meeting or discussion at the earliest appropriate opportunity;
• communicating in the person’s preferred language, format and method wherever reasonably practicable;
• involving a representative, advocate or placing authority where appropriate;
• providing written information or summaries where required;
• signposting to the Complaints Policy and available advocacy services;
• advising the individual or representative of external routes for raising concerns, including CIW and, where relevant, the Public Services Ombudsman for Wales.

The service will make reasonable adjustments to support participation and understanding. Where a person needs advocacy support, or has substantial difficulty in understanding, communicating or participating, staff will support access to advocacy in line with legal and policy requirements.

6. Related Policies

This policy works alongside:

• CHW11 – Safe Care and Treatment Policy
• CHW14 – Receiving and Acting on Complaints Policy
• CHW16 – Health and Safety at Work Policy
• CHW24 – Management of Accidents, Incidents, and Near Misses Policy
• CHW29 – Whistleblowing (Speaking Up) Policy
• CHW36 – Safeguarding Adults from Abuse and Improper Treatment Policy

7. Policy Review

This policy will be reviewed at least annually and sooner where there is:

• a change in legislation, statutory guidance, CIW requirements or Social Care Wales codes or guidance;
• a significant incident, complaint, safeguarding matter or enforcement issue;
• learning from audits, inspections or quality reviews which indicates amendment is required.

This policy must be specifically reviewed before 1 July 2026 to ensure alignment with the updated Social Care Wales Codes of Professional Practice.

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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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