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{{org_field_name}}

Registration Number: {{org_field_registration_no}}

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Duty of Candour Policy

1. Purpose

At {{org_field_name}}, we are committed to providing high-quality, safe, and compassionate care to all our service users. However, we recognise that despite best efforts, things can sometimes go wrong. When this happens, we have a legal and moral responsibility to be open and honest with service users, their families, and representatives.

This policy outlines our approach to fulfilling the Duty of Candour as required under Regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. It ensures that service users are informed of incidents that have affected their care, provided with an apology, and given an explanation of what happened and what actions will be taken to prevent recurrence.

2. Scope

This policy applies to all employees, agency workers, contractors, and volunteers working for {{org_field_name}}. It ensures that our organisation operates with transparency and integrity when responding to incidents where a service user has suffered harm or may be at risk of harm due to the care or treatment provided.

The Duty of Candour applies to all notifiable safety incidents, meaning those that have resulted in moderate or severe harm, prolonged psychological impact, or in the most serious cases, death. By embedding a culture of openness and honesty, we aim to build trust with service users and their families while continuously improving the quality of our services.

3. Policy Statement

At {{org_field_name}}, we are committed to:

• Being open and honest when things go wrong.
• Acknowledging mistakes and learning from them to prevent future occurrences.
• Providing timely and transparent communication to those affected by incidents.
• Issuing a genuine apology and explaining what happened and why.
• Ensuring all staff understand and fulfil their responsibilities under the Duty of Candour.

We believe that honesty is fundamental in maintaining the confidence of those who use our services. We will ensure that any incidents that meet the criteria for a notifiable safety incident are handled with integrity, professionalism, and empathy.

4. Definitions

4.1 Duty of Candour

The Duty of Candour is a legal obligation requiring health and social care providers to act in an open and transparent manner when something goes wrong that has caused or has the potential to cause harm to a service user.

4.2 Notifiable Safety Incident

A notifiable safety incident is defined as an unexpected or unintended event that occurs in the provision of care and results in:

• Death (not due to the underlying illness or condition).
• Severe harm (permanent disability or life-threatening harm).
• Moderate harm (requiring significant medical treatment or prolonged recovery).
• Prolonged psychological harm (lasting more than 28 days).

5. Responsibilities

5.1 Responsibilities of the Registered Manager

The Registered Manager is responsible for ensuring compliance with the Duty of Candour. Their role includes:

• Overseeing the reporting and management of notifiable safety incidents.
• Ensuring that service users and their families are informed promptly and appropriately.
• Training and supporting staff to understand and comply with the Duty of Candour.
• Submitting incident reports to the Care Quality Commission (CQC) where required.
• Reviewing incidents to identify learning opportunities and ensure service improvements.

5.2 Responsibilities of All Staff

All staff have a duty to:

• Report incidents, errors, and concerns immediately to their manager.

Where to report:

1) Verbally to the Registered Manager or Safeguarding Lead

2) Inform the Registered Manager by email: {{org_field_registered_manager_email}}

3) Call the office and inform the Registered Manager or Safeguarding Lead: {{org_field_phone_no}}

4) Out of hours phone number: {{out_of_hours}}

• Engage in open and honest communication with service users and families.
• Support those affected by an incident with compassion and understanding.
• Participate in training and development related to the Duty of Candour.

Failure to comply with this policy may result in disciplinary action, as transparency and honesty are fundamental values of our organisation.

6. Procedure for Managing a Notifiable Safety Incident

When a notifiable safety incident occurs, {{org_field_name}} follows a structured process to ensure transparency and compliance with the Duty of Candour.

Step 1: Immediate Notification

As soon as a notifiable safety incident is identified, the affected service user (or their representative) must be informed as soon as reasonably practicable. This discussion should be held in person by the Registered Manager or a senior member of staff and must be conducted with compassion and sensitivity.

Step 2: Providing a Clear Explanation

The following information must be shared with the service user and/or their representative:

• A factual account of what happened, without speculation.
• The immediate actions taken to ensure the safety of the service user.
• The potential impact of the incident on their health and well-being.
• The steps being taken to investigate and prevent recurrence.

If the service user lacks capacity, information should be shared with their legally appointed representative in line with the Mental Capacity Act 2005.

Step 3: Offering a Meaningful Apology

A sincere and genuine apology must be provided both verbally and in writing. This is not an admission of liability but an expression of regret and responsibility for the incident. The apology should acknowledge the distress caused and reassure the service user that lessons will be learned.

Step 4: Documenting the Incident

A detailed written record of the incident must be kept, including:

• The nature of the incident and what went wrong.
• The information provided to the service user.
• A copy of the written apology.
• Any actions taken to address and mitigate the incident.
• Plans for future prevention and improvement.

These records must be stored securely and be available for CQC inspection.

Step 5: Reporting the Incident to CQC

If the incident meets the criteria for a notifiable safety incident, the Registered Manager must report it to the Care Quality Commission (CQC) within the required timeframe.

Step 6: Learning and Improving

A full internal investigation must take place to determine root causes and ensure preventative measures are put in place. Any necessary changes in policies, training, or procedures must be implemented to reduce the likelihood of similar incidents in the future.

7. Training and Awareness

All staff must receive comprehensive Duty of Candour training as part of their induction and ongoing professional development. Training will cover:

• The legal and ethical responsibilities under the Duty of Candour.
• How to communicate effectively with service users and families after an incident.
• The importance of offering a meaningful apology.
• The process for reporting and documenting incidents.

Managers must also receive specific training on how to lead open conversations and manage serious incidents in a transparent manner.

8. Compliance and Monitoring

To ensure that this policy is followed consistently, the Registered Manager will:

• Conduct regular audits of incident reports and documentation.
• Collect feedback from service users to assess the effectiveness of communication.
• Take corrective actions where necessary to address gaps in compliance.

Any failure to adhere to the Duty of Candour requirements will be addressed through additional training and, if necessary, disciplinary action.

9. References

• Regulation 20: Duty of Candour, Health and Social Care Act 2008 (Regulated Activities) Regulations 2014​.
• CQC Guidance on Duty of Candour.
• Mental Capacity Act 2005.

10. Review Date This policy will be reviewed annually or sooner if regulatory updates or best practices change.

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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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