The CQC's latest COVID-19 Insight report addresses the important issue of closed cultures and how they create significant risks for safe and effective patient care. After the issues that were revealed at Whorlton Hall, Winterbourne View, Mid Staffordshire Hospital and other services, the CQC’s investigations highlighted serious failings that resulted from closed cultures, and the impact that these had on people using services.

What are closed cultures?

The CQC defines a closed culture as “a poor culture that can lead to harm, including human rights breaches, such as abuse”. Closed cultures - and the possible dangers that they cause - can happen across a wide range of health and social care settings, but some services are more at risk than others, such as care homes or those that house people with learning disabilities or autism.

While it is only natural to look for a single, simple root cause, the risk factors that contribute to closed cultures are often more complex and varied, but many of the most common include:

• Patients being placed in services far from their family, friends and communities
• Patients being placed in inappropriate environments for months or years at a time
• Poor or weak leadership within a service
• Staff lacking the right skills, training or experience to properly support patients
• A culture that lacks positive and open engagement and communication between staff, and with people who use services and their families

Identifying and taking action on closed cultures is a central part of the CQC’s regulatory work, so the issue is of course high on their agenda. However, they recognised that the issues caused by closed cultures were made worse during the pandemic due to the serious challenges posed by reduced external oversight, fewer visitors, and staffing shortages that caused overworked teams to cut corners, or pressured management teams to miss - or even deliberately overlook – areas of poor performance for the sake of expedience.

Poor incident reporting

One of the issues of closed cultures is that of poor incident reporting, where underperforming services either delayed notifying anyone about important issues or did not report them at all. In most cases, this was unintentional and due simply to poor and/or inefficient processes, but in some cases, the poor incident reporting was intentional and made in an effort to avoid blame for issues by deliberately concealing them from the CQC or from higher management.

In some instances, the problem was caused not by a lack of honesty or transparency, but by a hostile culture where staff felt too intimidated to report incidents that they observed or felt powerless to escalate serious risks. Indeed, the CQC’s investigations revealed incidences of a “cover-up culture”, where some services were not transparent about incidents or concerns raised by staff or people using the service.

This included claims of under-reporting of “violence between people using the service, people being unable to access the police or social workers following cases of abuse, and managers being unwilling to investigate concerns”. Staff in these services were not encouraged to speak up, and in some services staff were explicitly told not to report incidents or raise concerns.

Unclear ownership and failing leadership

One cause of these issues that the CQC identified is that of unclear accountability and ownership. By failing to clearly assign ownership and responsibilities for critical actions, objectives and outcomes, risks went unaddressed, critical decisions were left unmade and problems were exacerbated. Because services did not have efficient systems in place to adequately track actions, monitor progress and clearly communicate goals and priorities, their actions were unaligned with their priority outcomes, leading to wasted effort and ultimately, unsafe practices and poor-quality care.

Similarly, those services that suffered from closed cultures also exhibited symptoms of a lack of leadership and oversight, where management failed to learn from previous incidents or failed to act to prevent recurring incidents. By failing to log and track actions and decisions and their impacts, management often failed to identify recurring issues, failed to address poor staff performance, and failed to prevent repeated lapses in proper care.

The right tool for the job

Many, if not all of the issues arising from closed cultures in healthcare could be improved or alleviated with a clear, integrated and robust risk management system that helps everyone in the organisation:

• Understand what the risks are
• Identify the warning signs
• Clearly and quickly report identified incidents
• Escalate areas of particular concern

At the same time healthcare service providers would derive huge cultural and safety benefits from a system that provided clear, safe channels for reporting and escalating risks, and that provided all the relevant data in one place to help management clearly see the impacts of their decisions and learn from them in order to avoid future, repeated mistakes. Likewise, such a system would give everyone in the organisation - from ward to board – a clear oversight of actions, showing who is responsible for doing what, and when, and how their actions are progressing.

Technology alone cannot address these issues unless it is embraced and used to its fullest potential. But it’s clear that when used properly and completely, the right risk and quality management platform can make it significantly easier for management and staff alike to deliver safe, efficient care in a supportive and proactive atmosphere and help put paid to the dangers posed by closed cultures.

Robert Hobbs

Chief Executive Officer

InPhase’s Chief Executive and Founder, Robert has been the visionary leading InPhase to be one of the UK's leading providers of management, governance and assurance solutions, and helping organisations align their actions and goals more easily and efficiently with InPhase's suite of integrated apps.