I'm sure when most of us go to bed at night, we lock the doors. I suspect many people feel safer with their doors locked most of the time. In health and social care services there is, perhaps, a perception that people are receiving safer care if the premises (or part of the premises) are secured to prevent people 'escaping' and to discourage people from entering unannounced. Is that a reasonable perception though?
Does security equate with safer environments or does it mean isolation and higher risk to the most vulnerable?
The Glynis Murphy review of how the Care Quality Commission responded to to the concerns about Whorlton Hall, a large facility for people with learning disabilities, some of whom were detained under the Mental Health Act was published in 2020. It offered six recommendations for CQC which were;
Prioritising gathering information from people with learning disabilities and families during and between inspections via thorough interviews including the use of reasonable adjustments e.g. talking mats
Using information already gathered on services to create a list of ‘red flags’ for a service at risk of abuse or restrictive practices
More flexible inspections when there is a risk identified/continuous Requires Improvement rating i.e. longer and more thorough inspections; reduced need for overwhelming evidence allowing inspectors to go in earlier where there is a concern.
More inspections in the evenings and at the weekends including unannounced inspections
No longer allowing the registration or expansion of isolated services
Taking abuse seriously when it is uncovered and improving reaction to whistleblowing and complaints by recognising that this is probably the ‘tip of the iceberg’
Whilst the recommendations are for the Care Quality Commission, they offer insight for providers wanting to ensure that they avoid their service developing a closed culture and that they are building safe environments, that are welcoming and open to external oversight and scrutiny. The recommendations focus very much on services for people with learning disabilities. but cultural improvements and care governance can be applied in many settings where people are hidden from view; the risks associated with a closed culture apply to many settings and many people. Cultural changes can be insidious and pervasive. A once beautiful care home in park like grounds that offered genteel care for the frail elderly can evolve as people's levels of dependency increase and recruiting the right staff becomes ever more difficult. An able bodied person, able to drive and access activities, work and social contacts may consider a beautiful country mansion away from main roads and public transport idyllic. However, for someone unable to venture out without support or unable to use WhatsApp, Zoom, FaceTime or other social media platforms, they can become gilded prisons and places of isolation, fear and even abuse.
So what is a closed culture? It is an environment that can result in harm to very vulnerable people, including abuse and dismissal of people's human rights. Any service that delivers care can have a closed culture. Particularly where staff no longer see people using the service as individuals, but allow them to become tasks and pieces of work that need 'sorting'. Within such environments there may be very few people who are able to speak up for themselves, either because for their own communication challenges, or because of organisational oppression and fear of retribution. The root causes are manifold, but it is the outcomes that are important: Understanding the risks, the triggers and ways of preventing a decline in staff behaviours and attitudes is essential in providing a safe environment.
Things that might increase the risks or be suggestive of a closed culture include;
Very vulnerable people who cannot easily communicate their wishes or speak about their experiences, without high levels of support.
People are often accommodated at the service for months or years.
They may be placed a long way from their original home and away from family or friends.
Registered managers are often absent or a manager is not in day to day charge of the unit. Senior staff do not visit often and do not meet with people using the service.
There may be cliques of staff who 'have each others backs' - often people who are related who socialise outside of work in their tight knit group. Rota's allow staff to choose to work together frequently.
High staff turnover, frequent absences and staff persistent shortages.
The service is in an isolated or remote, rural setting
There is little engagement with external agencies and reluctant information sharing.
There are few visitors.
I remember (going back a good few years) a care home group that refused to acknowledge that they were a care home. They preferred the term 'hotel'. They catered for people that were embarrassed at their increasing frailty and offered 'discreet care'. The food was excellent. The premises were architecturally impressive, with sweeping wide staircases, flock wallpaper and thick dense carpets. Families left their elderly relatives here knowing they were receiving the very best of care. They trusted to the expertise of the staff. In the basement there was a person sitting in a filthy domestic reclining chair; they were wearing soiled clothing and looked unkempt. This person had lost mobility and was trapped in the chair, unable to to stand, to change position or to move from the chair unaided. They had no call bell as they were 'disruptive' and kept calling the staff unnecessarily. They were a big person and also slept in the chair. They were changed twice a day when there were two male staff on duty who were able to lift them. No hoist would fit into the small basement room and there was no lift to that level. The person had very significant pressure damage and was clearly in pain. They had been forgotten by nearly everyone. Obviously, we arranged transfer to hospital and then took action to close the service and the other homes in the group, but it should never have been allowed to happen in the first place. This was pre-CQC days but still several agencies should have had better oversight of the risks this service posed to people. Oddly, the provider genuinely thought they were providing high quality care by maintaining a façade of genteel normality and hiding away those whose condition rendered them at odds with the image they wanted to portray.
What can staff, managers and providers do to reduce the risk of a closed culture developing in their service?
Sometimes the obvious and simple answers are the most effective. Lots of spreadsheets and action plans won't make it happen: It is about ensuring the reality matches the rhetoric and that the people in the service remain visible and remain heard. Its also about caring for your staff, offering opportunities for learning, valuing them, recognising their good practice.
CQC has recently published a Quality of Life tool, developed with Warwick University, and available on the Commission website. It is aimed at services for people with learning disabilities and autism, but is also applicable to many other types of service from homes for people living with dementia, mental health in-patient units and elderly care wards in community hospitals to neuro-rehabilitation centres and wards or units for people with post-coma unresponsiveness or needing long-term ventilation. One could argue the risk of closed cultures also applied to less obvious settings such as maternity units and child mental health in-patient facilities. Certainly there have been schools and children's homes where the risks have been realised. It is a useful read for anyone working in health and social care and can be found at Quality of life tool for inspecting services for people with a learning disability | Care Quality Commission (cqc.org.uk)
You can ensure good, values based recruitment with a comprehensive induction and training programme.
You can ensure a competent and committed registered manager is appointed who has sufficient time to run the service effectively and who is supported to address any concerns.
You can devise ways of enabling people using the service to be heard, really heard. Through technology, the use of independent advocates, corporate a senior staff spending time listening to the hardest to reach and through open communication with families or other representatives. The pandemic has certainly exacerbated isolation, but many services have found new ways to ensure people stay in touch.
You can encourage staff to speak about any concerns they have and develop a culture where staff feel listened to.
You can pro-actively seek feedback from people using the service, staff, families, visiting professionals, corporate visitors and commissioners. You can act on that feedback.
You can invite external scrutiny and opinion. Rarely, someone may be unable to tolerate the presence of strangers visiting or attempting to engage with them (or their families) but they are the minority and that should not stop others enjoying visits from a range of people. Perhaps from an advocacy service, a chaplain or other religious minister, an interpreter for people who use Makaton, BSL or EAL, someone from Health watch, perhaps. You can ensure family are welcomed and their visits are made comfortable and easy (assuming the person wants them to visit).
If you commission services or are in a corporate role, you can make sure you speak with or at least see the people you are commissioning or providing services for and you can speak to staff. As Glynis Murphy suggests, perhaps some of those cooperate, board or commissioning visits should be outside of usual working hours and should be unannounced. I would suggest internal 'mock inspection' reports or provider visits were routinely shared with the people using the service or their families and representatives.
Adopting a high reporting/low harm focus and a zero tolerance of any potential abuse directed towards anyone using the service.
Mainly, it is about ensuring that the voice of those hidden from view is both heard and respected. Caring can be a very, very hard job, but providing good care and supporting staff to provide good care feels much, much better than working in an abusive or dehumanising culture.