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{{org_field_name}}

Registration Number: {{org_field_registration_no}}

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Open Door Policy

1. Purpose

The purpose of this policy is to ensure that {{org_field_name}} fosters a transparent, supportive and inclusive environment in which employees, individuals receiving care and support, their representatives, families and relevant external stakeholders feel able to raise concerns, share ideas and provide feedback.

The Open Door Policy supports a culture in which concerns are welcomed, considered appropriately and used to improve the quality and safety of the service. It does not replace the organisation’s formal Complaints, Whistleblowing, Safeguarding or Grievance procedures. Where a matter falls within one of those procedures, it will be managed and escalated under the appropriate policy.

This policy ensures that:

• Staff are supported and encouraged to raise concerns, including concerns about the health, safety or well-being of individuals receiving care and support.
• Individuals receiving care and support and, where appropriate, their representatives are able to raise concerns, express their views and provide feedback.
• Managers are accessible and concerns are considered promptly and appropriately.
• Concerns relating to abuse, neglect or improper treatment are acted upon immediately and referred through the appropriate safeguarding arrangements.
• The organisation acts openly and transparently with individuals receiving care and support and their representatives in accordance with its statutory duty of candour.
• Feedback, concerns, complaints, safeguarding matters and whistleblowing information are recorded, reviewed and used, where relevant, to monitor and improve the quality of the service.
• No individual is disadvantaged, victimised or treated adversely because they have raised a genuine concern or complaint.

This policy must be read and applied in accordance with:

• The Regulation and Inspection of Social Care (Wales) Act 2016.
• The Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended.
• The Welsh Government statutory guidance for service providers and responsible individuals on meeting the service standard regulations for care home and domiciliary support services, as amended or replaced.
• The Social Services and Well-being (Wales) Act 2014.
• The Equality Act 2010.
• The Public Interest Disclosure Act 1998 and the relevant provisions of the Employment Rights Act 1996 relating to protected disclosures.
• Applicable data protection legislation, including the UK General Data Protection Regulation and the Data Protection Act 2018.
• The Code of Professional Practice for Social Care Workers and the Code of Professional Practice for Social Care Employers issued by Social Care Wales under section 112 of the Regulation and Inspection of Social Care (Wales) Act 2016.
• The Wales Safeguarding Procedures.

Where legislation, statutory guidance or regulatory requirements are amended, the most current requirements will apply.

2. Scope

This policy applies to:

• All employees of {{org_field_name}}, including care workers, supervisors, and management.
• Service users, their families, and advocates who wish to raise concerns, suggestions, or feedback.
• External stakeholders, including healthcare professionals, local authorities, and regulators.

This policy covers:

• Access to management for employees, service users, and families.
• Confidentiality and safeguarding of reported concerns.
• Processes for addressing feedback, concerns, and suggestions.
• Protection against retaliation for raising concerns.

3. Policy Statement

{{org_field_name}} is committed to maintaining a culture of openness, honesty, and responsiveness. Our Open Door Policy ensures that:

• All employees, service users, and external stakeholders feel confident in expressing concerns, ideas, and feedback.
• Managers are accessible, approachable, and responsive to concerns.
• Feedback mechanisms are clearly defined and respected.
• Concerns are addressed efficiently, fairly, and confidentially.

4. Managing the Open Door Policy Efficiently

4.1. Encouraging Open Communication

To ensure effective communication, {{org_field_name}} will:

• Encourage employees to discuss workplace concerns directly with management.
• Provide a safe space for service users and families to raise issues regarding their care.
• Promote a no-blame culture, ensuring that concerns and ideas are received positively.
• Ensure managers have an ‘open door’ policy in practice, making themselves available for discussions when needed.

All communication will be handled professionally and respectfully, promoting a culture of mutual trust.

4.2. Raising Concerns and Accessing Management

{{org_field_name}} will provide accessible routes through which staff, individuals receiving care and support, representatives, families and relevant stakeholders may raise concerns or provide feedback.

The Open Door process does not prevent or delay any person from using the organisation’s formal Complaints, Whistleblowing, Safeguarding or Grievance procedures or from raising a matter with an appropriate external authority.

For Employees and Other Persons Working at the Service

Employees, workers, agency staff, contractors and volunteers may raise ordinary workplace concerns, suggestions or feedback through:

• A face-to-face discussion with their line manager, Registered Manager or another appropriate senior manager.
• A scheduled supervision or other management meeting.
• Written communication, including email or an appropriate internal reporting mechanism.
• The organisation’s grievance procedure where the matter relates to the individual employee’s own employment.

Where a member of staff or another person working at the service has a concern about malpractice, wrongdoing, unsafe practice or any matter which may adversely affect the health, safety or well-being of an individual receiving care and support, the matter must be dealt with in accordance with the Whistleblowing Policy (DCW29).

A person raising a whistleblowing concern is not required to raise the matter first with the person who is the subject of the concern. Where appropriate, concerns may be raised directly with the Registered Manager, Responsible Individual, another designated senior person or an appropriate external body in accordance with the Whistleblowing Policy.

Nothing in this Open Door Policy prevents a worker from making a protected disclosure in accordance with applicable whistleblowing legislation.

For Individuals Receiving Care and Support, Representatives and Families

Individuals receiving care and support and, where appropriate, their representatives or families may:

• Speak directly to a care worker, coordinator, Registered Manager or another appropriate member of staff.
• Request a meeting with the Registered Manager or other appropriate manager.
• Provide feedback verbally or in writing.
• Raise a concern or make a complaint under the Receiving and Acting on Complaints Policy (DCW14).

Where an expression of dissatisfaction constitutes a complaint, it must be dealt with in accordance with the organisation’s Complaints Policy and Procedure. A person must not be disadvantaged, victimised or experience withdrawal or reduction of a service because they have raised a concern or made a complaint.

For External Stakeholders

Relevant external stakeholders, including commissioners and health or social care professionals, may raise concerns directly with the Registered Manager, Responsible Individual or other appropriate senior person.

Nothing in this policy prevents any person from contacting Care Inspectorate Wales, a local authority safeguarding service, the police or another relevant statutory or regulatory body where they are entitled or required to do so.

Urgent and Safeguarding Concerns

Any concern indicating actual or suspected abuse, neglect, improper treatment or an immediate risk to an individual’s safety or well-being must not be dealt with solely through the informal Open Door process. Immediate protective action must be taken and the matter must be managed in accordance with the organisation’s safeguarding procedures and the Wales Safeguarding Procedures.

Concerns will be acknowledged and responded to appropriately according to their nature and level of risk. Where a concern constitutes a formal complaint, safeguarding matter or whistleblowing concern, the timescales and procedures contained in the relevant policy will apply.

4.3. Confidentiality, Information Sharing and Safeguarding

Concerns and information disclosed under this policy will be handled sensitively and confidentially so far as is lawful and practicable. Information will only be accessed, used or shared where there is a legitimate need to do so and in accordance with applicable data protection, confidentiality, safeguarding and regulatory requirements.

{{org_field_name}} cannot guarantee absolute confidentiality. Information may need to be shared where:

• There is an actual or suspected safeguarding concern involving abuse, neglect or improper treatment.
• There is an immediate or significant risk to the health, safety or well-being of an individual or another person.
• Disclosure is required by law, a court, Care Inspectorate Wales or another body exercising lawful statutory functions.
• Information must be provided to the local authority, police, Disclosure and Barring Service, Social Care Wales or another relevant professional or regulatory body.
• Disclosure is necessary to investigate a concern properly or to take appropriate protective or corrective action.

Wherever appropriate, the person raising the concern will be informed about how information relating to the concern will be used or shared. Consent will be sought where this is appropriate, but lack of consent will not prevent information being shared where there is a lawful safeguarding, regulatory or other legal basis for doing so.

Where there is an allegation or evidence of abuse, neglect or improper treatment, {{org_field_name}} will:

• Take immediate action to ensure the safety of individuals receiving care and support.
• Act in accordance with the organisation’s safeguarding policies and procedures and the Wales Safeguarding Procedures.
• Make appropriate referrals to the local authority and/or other relevant agencies.
• Notify Care Inspectorate Wales where a notification is required by the applicable Regulations.
• Keep an accurate record of the allegation or evidence, the action taken, referrals made and outcomes known to the service.

Safeguarding concerns must be escalated in accordance with the organisation’s applicable safeguarding policy and must not be delayed while an issue is being considered through the Open Door process.

4.4. Duty of Candour and Openness When Things Go Wrong

{{org_field_name}} and the Responsible Individual will act in an open and transparent manner with individuals receiving care and support and, where appropriate, their representatives.

Where something has gone wrong in connection with the care and support provided, the service will promote and maintain a culture of candour. This includes:

• Being open and honest with the individual and, where appropriate, their representative.
• Providing appropriate information about what has happened.
• Providing appropriate information about the outcome of any investigation or review.
• Explaining any action being taken to protect individuals or prevent a recurrence.
• Offering an apology where it is appropriate to do so.
• Recording the matter and any actions taken in accordance with the organisation’s record-keeping requirements.
• Making any safeguarding, regulatory or other statutory notification required by law.

No board member, Responsible Individual, manager or member of staff may obstruct another person from acting openly and honestly in accordance with a professional or statutory duty of candour.

Any suspected breach of a professional duty of candour by a professionally registered worker will be considered appropriately and, where required, referred to the relevant professional regulator.

Staff will be supported to report adverse incidents, mistakes and concerns openly so that appropriate action can be taken and learning can be used to improve the service. Bullying, harassment or victimisation associated with a person exercising a duty of candour will not be tolerated.

4.5. Handling, Recording and Resolving Concerns

When a concern is received under this policy, the person receiving it must first determine the nature and urgency of the matter and ensure that it is directed into the appropriate procedure.

The following principles will apply:

1. Immediate safety – Where there is an immediate risk to an individual’s health, safety or well-being, action to protect the individual must take priority.
2. Initial consideration – The concern will be considered promptly to determine whether it should be managed as:
   • General feedback or an informal concern.
   • A formal complaint.
   • A safeguarding concern.
   • A whistleblowing concern.
   • An employment grievance.
   • A disciplinary or conduct matter.
   • An incident or event requiring notification to Care Inspectorate Wales or another statutory body.
3. Referral to the correct procedure – Where another formal policy or statutory procedure applies, the concern will be managed under that process. The Open Door process must not be used to avoid, replace or delay statutory safeguarding, complaints, whistleblowing, disciplinary or regulatory requirements.
4. Investigation and action – Concerns requiring investigation will be considered by a person with appropriate authority, knowledge and competence. Appropriate action will be taken following the investigation.
5. Response – Where reasonably practicable and lawful, the person who raised the concern will be informed of the outcome or response. Information relating to other individuals will only be disclosed where lawful and appropriate.
6. Recording – An appropriate record will be maintained of the concern, its classification, any investigation undertaken, decisions made, referrals or notifications made, action taken and, where applicable, the outcome.
7. Learning and improvement – Information from concerns, complaints, safeguarding matters and whistleblowing will be monitored for themes, trends, recurring risks and opportunities to improve the quality and safety of the service.

Where the matter is a formal complaint, it will be handled in accordance with the Receiving and Acting on Complaints Policy (DCW14). Where the matter is a whistleblowing concern, it will be handled in accordance with the Whistleblowing Policy (DCW29). Where the matter raises a safeguarding concern, the organisation’s safeguarding procedure and the Wales Safeguarding Procedures will apply.

4.6. Protection for People Raising Concerns

{{org_field_name}} will not tolerate victimisation, bullying, harassment or other adverse treatment of a person because they have raised a genuine concern, made a complaint, reported a safeguarding matter or supported an investigation.

Workers who make a qualifying protected disclosure are protected in accordance with applicable whistleblowing legislation. The organisation’s Whistleblowing Policy (DCW29) sets out the procedure for making such disclosures and the safeguards available to workers.

Employees and other persons working at the service will be encouraged and supported to raise concerns about any matter which may adversely affect the health, safety or well-being of individuals receiving care and support.

Individuals receiving care and support must not suffer victimisation, disadvantage, or withdrawal or reduction of their service because they have raised a concern or made a complaint.

A person raising a concern is not required to approach an individual who is implicated in the concern. Alternative internal reporting routes will be available through the Registered Manager, Responsible Individual or other appropriate senior person.

Nothing in this policy prevents a person from raising a concern directly with Care Inspectorate Wales, the local authority, the police, Social Care Wales, the Disclosure and Barring Service or another appropriate statutory, professional or regulatory body where they are entitled or required to do so.

Any allegation that a person has been victimised or subjected to retaliation for raising a concern will itself be treated seriously and considered under the appropriate organisational procedure.

4.7. Monitoring, Oversight and Continuous Improvement

{{org_field_name}} will maintain effective arrangements for monitoring, reviewing and improving the quality of care and support provided by the service.

As part of those arrangements, the service will encourage feedback and seek the views of:

• Individuals receiving care and support.
• Their representatives, unless this would be inappropriate or inconsistent with the individual’s well-being.
• Service commissioners.
• Staff working at the service.

Methods used to obtain feedback will be appropriate to the individual’s communication needs, level of understanding and circumstances, and support will be provided where necessary to enable meaningful participation.

Concerns and feedback received under this policy will be recorded and, where appropriate, analysed alongside information about:

• Complaints.
• Safeguarding matters.
• Whistleblowing concerns.
• Incidents and notifiable events.
• Feedback from individuals, representatives, commissioners and staff.
• Actions taken and lessons learned.

The Responsible Individual will ensure that the quality of care and support is formally reviewed as often as required and at least every six months in accordance with the Regulations. The review will include consideration of aggregated information relating to incidents, notifiable incidents, safeguarding matters, whistleblowing, concerns and complaints and any actions taken in response.

The Responsible Individual will report on the quality of care and support in accordance with their regulatory duties and make recommendations to the service provider for improvement.

Where monitoring identifies a risk to the quality or safety of the service, appropriate action will be taken without delay. Learning arising from concerns, complaints, safeguarding matters and whistleblowing will be shared with relevant staff and used to improve practice and service delivery.

5. Related Policies and Procedures

This policy must be read alongside, and does not replace, the following policies and procedures:

• Receiving and Acting on Complaints Policy (DCW14).
• Whistleblowing Policy (DCW29).
• Safeguarding Adults from Abuse and Improper Treatment Policy (DCW13), together with any separate safeguarding policy applicable to children where the service provides care and support to children.
• Equality, Diversity and Inclusion Policy (DCW30).
• Staff Supervision, Training and Development Policy (DCW27).
• Grievance Policy (DCW28).
• Disciplinary Policy and Procedure.
• Data Protection and Confidentiality Policy.
• Incident Reporting and CIW Notification Procedure.

Where a concern raised under this Open Door Policy meets the criteria for action under another policy or statutory procedure, the requirements of that policy or procedure will take precedence and must be followed without delay.

6. Policy Review

The Responsible Individual will ensure that suitable arrangements are in place for this policy to be kept up to date, having regard to the Statement of Purpose and the requirements applicable to the regulated service.

This policy will be formally reviewed at least annually and sooner where necessary, including where there is:

• A change in legislation, regulations, statutory guidance, CIW requirements or applicable Social Care Wales requirements.
• A change to the organisation’s Statement of Purpose which affects this policy.
• Learning arising from a concern, complaint, safeguarding matter, whistleblowing concern, incident or regulatory inspection.
• Evidence from quality assurance activity that the policy is not operating effectively.
• A material change in organisational arrangements or responsibilities.

Where changes to this policy directly affect individuals receiving care and support and/or their representatives, relevant changes will be communicated to them in a timely and accessible manner.

Staff and volunteers will have access to the current version of this policy and will be made aware of any changes relevant to their roles and responsibilities.

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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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