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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 establish a clear, comprehensive, and legally compliant approach to fulfilling the statutory Duty of Candour as set out in Regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014​. This policy applies to all activities undertaken by {{org_field_name}}, including the placement of Registered Nurses (RNs) and Healthcare Assistants (HCAs) into care homes, nursing homes, and other regulated environments. The Duty of Candour requires {{org_field_name}} to be open and honest with service users, families, clients, commissioners, and regulators when things go wrong, especially when a “notifiable safety incident” has occurred. This policy outlines the duties of the directors, staff, and all temporary workers engaged by {{org_field_name}} to promote a transparent and open culture and manage such incidents efficiently and sensitively. This document also explains how the director(s) will manage and monitor compliance to ensure the agency consistently meets its legal obligations and good practice expectations.

2. Scope

This policy applies to:

• All temporary workers employed or engaged by {{org_field_name}}, including those on zero-hours contracts
• All directors, administrators, and other employees involved in the provision of care or management of services
• All services, including placements within care homes and other client settings
• All interactions with clients, service users, families, advocates, and professional bodies This policy is essential reading for staff, clients, regulators (including the Care Quality Commission), and other stakeholders who require assurance that {{org_field_name}} operates transparently, upholds the rights of individuals, and places safety and openness at the heart of its operations.

3. Related Policies

• Incident Reporting and Management Policy
• Safeguarding Policy
• Complaints Policy
• Whistleblowing Policy
• Recruitment Policy
• Temporary Staffing Handbook
• Health and Safety Policy

4. Legal and Regulatory Framework

This policy is aligned with:

• Regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014​
• The Care Act 2014
• The Agency Workers Regulations 2010​
• The Health and Safety at Work etc. Act 1974​
• The Data Protection Act 2018 (GDPR)
• Employment Rights Act 1996​
• The Human Rights Act 1998

The Duty of Candour applies both to the registered provider of services and, by extension, to all agency workers provided by {{org_field_name}} when carrying out care duties in client establishments.

5. Definition of Duty of Candour

The Duty of Candour is a legal requirement to:

• Be open and honest with clients, service users, and relevant persons when something goes wrong with their care or treatment and causes, or could cause, significant harm
• Notify affected individuals and relevant parties as soon as reasonably practicable after a notifiable safety incident occurs
• Provide a truthful account of what happened, offer an apology, and explain what will be done to prevent recurrence

A “notifiable safety incident” is an unintended or unexpected incident that, in the reasonable opinion of a healthcare professional, appears to have resulted in:

• Death
• Severe harm
• Moderate harm
• Prolonged psychological harm It is important to note that near misses, although not legally notifiable, must still be reported internally and may require an apology if distress has been caused.

6. Managing the Duty of Candour Efficiently

6.1 Director(s) Responsibilities

As {{org_field_name}} does not have a registered manager, the director(s) take full accountability for:

• Promoting a culture of openness and transparency
• Ensuring all staff are aware of their Duty of Candour obligations
• Managing incidents and investigations
• Communicating effectively with affected parties
• Ensuring accurate documentation and timely notifications
• Liaising with external bodies such as the Care Quality Commission, safeguarding boards, and commissioners where necessary

The director(s) will ensure:

• The Duty of Candour is incorporated into all induction and mandatory training
• Incident reporting procedures clearly identify when a notifiable safety incident has occurred
• Action plans are produced following every notifiable incident
• Lessons learned are shared with staff and, where appropriate, with clients

6.2 Temporary Workers’ Responsibilities

Temporary workers, including nurses and HCAs, must:

• Immediately report any incident, near miss, or concern to the client and {{org_field_name}}
• Record the facts clearly and accurately
• Cooperate fully with any investigation
• Support the client’s Duty of Candour process on-site
• Treat affected service users and families sensitively and respectfully

Agency workers must not attempt to manage notifiable incidents independently but must report immediately to the director(s).

6.3 Incident Identification and Reporting

All staff must report:

• Unexpected deaths
• Accidents resulting in injury, harm, or distress
• Safeguarding concerns
• Medication errors
• Near misses that could have caused significant harm
• Complaints linked to potential safety incidents

Incidents should be reported to {{org_field_name}} without delay, using the established incident reporting form or direct communication with the director(s).

6.4 Communication with Affected Parties

When a notifiable incident occurs, the director(s) will:

• Notify the affected person or their representative as soon as possible, verbally and followed by a written account
• Explain the facts known at that stage
• Offer a sincere apology, recognising that apologies are not admissions of liability
• Keep the affected person updated regularly
• Provide written confirmation of the outcome of the investigation

All communications will be honest, sensitive, and supportive, acknowledging the emotional impact on those affected.

6.5 Record Keeping

{{org_field_name}} will maintain:

• A Duty of Candour Log
• Copies of all incident reports
• Written records of communications with affected individuals
• Investigation reports
• Action plans and lessons learned
• Evidence of compliance with Regulation 20

All records will be securely stored in accordance with the Data Protection Act 2018 (GDPR).

7. Training and Awareness

All temporary workers will be trained on the Duty of Candour during:

• Induction
• Mandatory annual refresher training
• Incident debriefing, where applicable

The director(s) will ensure that training includes:

• The legal basis for the Duty of Candour
• How to identify notifiable incidents
• How to report incidents effectively
• The importance of empathy and professionalism in communication

Agency staff will not be placed on assignment until they have completed Duty of Candour training.

8. Supporting Staff

{{org_field_name}} recognises that being involved in a notifiable incident can be distressing for staff. The director(s) will:

• Offer support, supervision, and debriefing
• Provide access to further advice if needed
• Promote a non-punitive approach unless there is evidence of deliberate wrongdoing, neglect, or malpractice

9. Quality Assurance and Audit

The director(s) will:

• Monitor incident trends quarterly
• Audit compliance with Duty of Candour requirements at least annually
• Record and act upon findings
• Update procedures where necessary
• Provide reports to clients or regulators if required

Audit outcomes and learning points will be shared with staff to promote continuous improvement.

10. Regulatory Notifications

The director(s) will ensure that notifiable incidents are reported externally where required, including:

• Care Quality Commission (CQC)
• Safeguarding Adults Board
• Commissioners
• Clients

Regulatory notifications will be made promptly and documented thoroughly.

11. Promoting a Culture of Openness

{{org_field_name}} is committed to:

• Fostering an environment where staff feel confident to report incidents
• Encouraging clients to report concerns
• Treating all reports with seriousness and sensitivity
• Ensuring that no worker or client suffers detriment for raising concerns

All agency workers are expected to uphold the principles of the Duty of Candour in their day-to-day practice.

12. Policy Governance and Review

This policy is owned by the director(s) of {{org_field_name}} who are responsible for:

• Implementing and overseeing the policy
• Ensuring compliance with legislation
• Reviewing the policy annually or sooner if required due to legislative or operational changes

The director(s) will make this policy available to:

• All staff during induction
• Clients on request
• Regulators during inspections

13. Policy Review

This policy will be reviewed annually by the director(s) of {{org_field_name}}, or earlier if:

• There are changes to legislation, regulations, or CQC guidance
• Audits, incidents, or staff feedback suggest the policy requires improvement
• Changes occur in organisational structure or procedures

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