Being Open and Honest – Duty of Candour Policy

Aim of Policy

This policy aims to improve the quality and consistency of communication when incidents involving clients, staff, or visitors occur and/or in situations which give rise to complaints. The policy will make sure that if mistakes are made, the clients and/or their carer, staff member, or visitor will be given an opportunity to discuss what went wrong, that they will receive an apology, and be informed of the action Seven Steps Support Ltd will take to prevent it happening again.

Our approach to candour underpins a commitment to providing a high quality of care, understanding and sharing the truths about harm at an organisational as well as an individual level, and learning from them. It is about our organisational values being rooted in genuine engagement of staff.

The processes contained within this policy reflect those set out in Regulation 20 and in the associated CQC guidance.

Definition of Terms

Being open

refers to the process for communicating adverse events with clients and their carers, staff, and visitors.

Candour:

“Any patient harmed by the provision of healthcare service is informed of the fact and an appropriate remedy offered, regardless of whether a complaint has been made or a question asked.” (Francis 2013)

Definitions of Levels of Harm

No harm:
- Impact prevented — any client safety incident that had the potential to cause harm but was prevented, resulting in no harm to people receiving care.
- Impact not prevented — any client safety incident that ran to completion but no harm occurred to people receiving care.
Low: Any client safety incident that required extra observation or minor treatment and caused minimal harm, to one or more persons receiving care.
Moderate: Any client safety incident that resulted in a moderate increase in treatment (e.g. increase in length of hospital stay by 4-15 days) and which caused significant but not permanent harm, to one or more persons receiving care.
Severe: Any client safety incident that appears to have resulted in permanent harm to one or more persons receiving care.
Death: Any client safety incident that directly resulted in the death of one or more persons receiving care.

Stage One

Incident identification and Reporting

Firstly, any actions that can be taken immediately to reduce the risk of harm to the client must be implemented. The initial facts of the incident should be established and an assessment of the level of harm that has happened to the patient as a result of the incident (see table below) should be undertaken.

No harm (including prevented patient safety incidents)
- Patients are not usually contacted or involved in investigations and these types of incidents are outside the scope of the Duty of Candour. Openness remains best practice, but there is no requirement to follow the Duty of Candour processes.
Low harm
- Unless there are specific indications or the patient requests it, the communication, investigation, and analysis, and the implementation of changes will occur at the local service delivery level with the participation of those directly involved in the incident. Communication should take the form of an open discussion between the staff providing the patient’s care and the patient and/or their carers. Reporting to the operational managers will occur through standard incident reporting and will be analyzed centrally to detect high-frequency events. Review will occur through aggregated trend data and local investigation. Where the trend data indicates a pattern of related events, further investigation and analysis may be needed. Openness remains best practice, but there is no requirement to follow the Duty of Candour processes for incidents that result in this level of harm.
Moderate harm, Severe harm, or death
- The Duty of Candour policy is implemented. Seven Steps Support Ltd operates within openness principles with our commissioners and regulators, and we will inform these organizations of the incident and the management plans as soon as possible.

Stage Two: Being Open

Principles for Being Open

Refer to Appendix 1 for a set of principles that staff should follow when communicating with the relevant person after an incident in which the client/service user was harmed.

Mental Capacity

If the client or service user lacks capacity to make decisions related to their care or treatment, or is under 16 and deemed not to have the necessary competency, notify the most appropriate relevant person of the incident.

Confidentiality

Treat details of a client’s care and treatment as confidential. Obtain the individual’s consent before disclosing confidential information to family or carers when fulfilling the Duty of Candour. Record this consent or denial of consent in the Care Plans. Limit communication with parties outside the management team to a need-to-know basis and anonymize records when possible.

The Relevant Person Cannot be Contacted or Declines to Have Further Information

If the client declines more information, explain the possible consequences and inform them that they can change their mind at any time. Record all Duty of Candour conversations, including instances when the client declines further information. If a relevant person cannot be contacted, document the attempts made to contact or speak to the person, showing that every reasonable effort was made.

Stage Three: Communication and Support

The initial ‘being open’ communications will vary depending on the individual needs, severity grading, outcome, and family circumstances for each specific event. The director and registered manager should coordinate this initial communication, ensuring the relevant person receives a clear explanation of the event and the next steps. Provide appropriate support to staff involved in the incident from the outset.

Apology

Offer an apology to the relevant person if a client safety incident caused harm — a sincere expression of sorrow or regret for any harm and distress caused.

Clarity of Communication

Take into account the individual communication needs of the relevant person, such as linguistic or cultural needs, learning disabilities, or sensory impairments, before any discussion takes place. This may involve providing additional support like an independent patient advisor or a translator.

Inform the relevant person of the issues surrounding the client safety incident and its consequences in a face-to-face meeting. Explain the known facts using clear, straightforward language, and be honest in responses to any questions raised. Inform the relevant person that an incident analysis will be conducted and more information will become available as it progresses.

Make it clear that new facts may emerge during the incident analysis. Establish the relevant person’s understanding of what happened and address any questions they may have. Consider and formally note the relevant person’s views and concerns, and demonstrate that they have been heard and taken seriously. Explain the next steps in terms of the long-term treatment plan for the patient and the incident analysis findings.

Share information on likely short and long-term effects of the incident (if known). Offer practical and emotional support to the relevant person. Clients, family, and/or carers might be anxious, angry, and frustrated, even when the discussion is conducted appropriately. Avoid speculation, attribution of blame, denial of responsibility, or the provision of conflicting information.

Stage Four: The Investigation

Serious Incidents

For Serious Incidents, the Investigating Officer (IO), which will be the directors, will undertake the investigation. The IO will meet with the employee(s) directly involved in the incident to establish the facts.

Significant Events

If an incident is notifiable but doesn’t meet the criteria for a Serious Incident, it will be classified as a ‘Significant Event’, and an investigation must be undertaken.

Follow the actions above with a letter to the client/relatives offering a meeting, if appropriate, written by the most suitable person. This may be before the conclusion of the investigation. An example template letter is provided in Appendix 4.

Inform the client of the independent advocacy services available to support and assist them.

Stage Five: Communication with the Relevant Person - The Notification Meeting

Arrange a meeting with the relevant person as soon as possible after the incident to notify them of the incident. This meeting should always take place within 10 working days of the incident being discovered.

Consider involving multiple staff members for support or additional information.

At the meeting, the nominated staff member should:

Explain what went wrong and why, if known
Inform the client and/or relatives of the steps being/will be taken to prevent the incident from recurring
Offer an apology
Provide an opportunity for the client and/or relatives to ask questions
Agree on any future meetings as appropriate
Suggest additional support and counseling resources, providing written information if appropriate
Inform the relevant person that they will receive a written summary of the incident and, if they wish, be informed of progress with the investigation. The relevant person will also receive a copy of the final investigation report.

Provide a named contact for the relevant person to speak to regarding the incident. This can be a manager or another staff member with the necessary skills and knowledge. Ensure the contact is aware of their role, agrees to it, and has all the information needed for clear and honest communication.

Inform the director for the service of the outcome of any meeting.

Record the communication and outcome of the notification in the notes by the person who informed the client/family.

Draft a letter to the relevant person immediately after the notification meeting, outlining what was explained. Forward the letter to the director for approval before sending it out. The letter must contain all the information provided at the initial notification meeting.

The regulations state that the notification given must be followed by a written notification containing:

(a) the information provided,
(b) details of any inquiries to be undertaken,
(c) the results of any further inquiries into the incident, and
(d) an apology.

Any Duty of Candour letters arising from the notification meeting must be signed off by the director and a copy kept in the notes.

If the client cannot be contacted in person or declines to speak to anyone from the organization about the incident, the above processes do not apply. However, keep a written record of the attempts made to contact or speak to the relevant person.

Stage Six: Investigation Closure and Learning

Closure and Communication

Once the incident is signed off for closure, send a letter to the relevant person together with the anonymized investigation report and action plan. The supporting letter should provide information in case the individual wishes to pursue legal action against the organization. Both directors must sign this letter.

Cascade all learning from the incidents throughout the organization.

Share the outcome of reports with any other healthcare organization or relevant stakeholder as appropriate to optimize learning from the incident.

Documentation

All correspondence should be held in accordance with our policies and procedures. With specific relation to the Being Open/Duty of Candour, the records must:

Record the sharing of any known and agreed-upon facts with the relevant person
Record how it has been agreed that the relevant person will be kept informed of the progress and results of the investigation
Record, where appropriate, a full apology to the client and their family/carers
Record any explanation given of the likely short and long-term effects of the incident
Contain copies of any letters sent to the relevant person
Record an offer of appropriate practical and emotional support

Performance/Disciplinary Issues

Seven Steps Support Ltd will strive to identify the underlying causes of client safety incidents, particularly in matters where safeguarding issues are identified. The appropriate professional body may also need to be notified.

Monitoring the Policy

Monitoring implementation will be undertaken as part of our auditing process.

Issue a questionnaire to staff who have been involved in Duty of Candour incidents to determine what extra support and resources need to be put in place to support staff in this process.