Duty of Candour Policy and Procedure

1. Governance

1.1. This is the Duty of Candour Policy and Procedure for The Good Place Home Care Services Limited.

1.2. The Good Place Home Care Services Limited will be referred to in this document as "The Good Place Home Care Services Limited","The Good Place","We","Us", or "Our".

1.3. Our registered address is: 186 Wetmore Road, Burton-on-Trent, Staffordshire, DE14 1QZ.

1.4. We can be contacted by:-

• a. Telephone: 01283 296 337
• b. Email: [protected:ahello][protected:athegoodplace.care]
• c. Post: The Good Place, 186 Wetmore Road, Burton-on-Trent, Staffordshire, DE14 1QZ

1.5. Words importing one gender include all genders, and words in the singular include the plural and vice versa, unless the context requires otherwise.

1.6. Document control sheet:-

2. Purpose

2.1. To comply with Duty of Candour as required under Regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

2.2. To ensure that we fulfil the legal and regulatory responsibilities.

2.3. To support us to meet, and be able to evidence compliance with, the following CQC Single Assessment Framework quality statements:-

3. Scope

3.1. This policy applies to all employees, agency workers, contractors, and volunteers working for The Good Place who are involved in the provision, management or oversight of any CQC-regulated domiciliary care or support delivered by us in people’s own homes.

3.2. The Duty of Candour applies to all notifiable safety incidents, meaning those that have resulted in moderate harm, severe harm, prolonged psychological harm, or death where this is directly related to the incident rather than the natural course of an illness or underlying condition. By embedding a culture of openness and honesty in all our work, including incidents below the notifiable safety incident threshold, we aim to build trust with service users and their families while continuously improving the quality of our services.

3.3. Where care is delivered in partnership with other organisations or professionals (for example GPs, community nurses, therapists or other providers), we will cooperate with them to support their own Duty of Candour responsibilities and ensure that people receive clear, coordinated information about any incident.

3.4. This policy should be read alongside our Incident Reporting, Safeguarding, Complaints, Risk Management and Whistleblowing policies, which together support an open and honest culture.

4. Policy Statement

4.1. At The Good Place, we are committed to providing high-quality, safe, and compassionate care to all our service users. However, we recognise that despite best efforts, things can sometimes go wrong. When this happens, we have a legal and moral responsibility to be open and honest with service users, their families, and representatives.

4.2. This policy outlines our approach to fulfilling the Duty of Candour as required under Regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. It ensures that service users are informed of incidents that have affected their care, provided with an apology, and given an explanation of what happened and what actions will be taken to prevent recurrence.

4.3. At The Good Place, we are committed to:-

• a. Being open and honest when things go wrong.
• b. Acknowledging mistakes and learning from them to prevent future occurrences.
• c. Providing timely and transparent communication to those affected by incidents.
• d. Issuing a genuine apology and explaining what happened and why.
• e. Ensuring all staff understand and fulfil their responsibilities under the Duty of Candour.
• f. Creating a culture where staff feel psychologically safe to speak up about incidents, near misses, concerns and mistakes without fear of blame, unfair treatment or detriment, so that we can learn and improve.
• g. Recognising the impact that serious incidents and investigations can have on staff and ensuring that appropriate support, debrief and supervision are available.

4.4. We believe that honesty is fundamental in maintaining the confidence of those who use our services. We will ensure that any incidents that meet the criteria for a notifiable safety incident are handled with integrity, professionalism, and empathy.

4.5. We will ensure that our approach to the Duty of Candour is consistent with our Raising Concerns, Freedom to Speak Up and Whistleblowing Policy and Procedure and Complaints Policy and Procedure and that people and staff are encouraged and supported to raise concerns about safety, quality or honesty.

5. Legal & Regulatory Framework

5.1. This policy is guided by:-

• a. Regulation 20: Duty of Candour, Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (as amended).
• b. Care Quality Commission (CQC) guidance for providers on the Duty of Candour (including the most recent online guidance, forms and notification requirements as updated by CQC).
• c. Mental Capacity Act 2005 and its Code of Practice.
• d. Care Act 2014 and local safeguarding adults policies and procedures.
• e. Equality Act 2010 and the Human Rights Act 1998.

5.2. Where required, we will also comply with related statutory reporting duties, for example to the local authority safeguarding team, the Health and Safety Executive (RIDDOR), the coroner, or the police, alongside meeting our Duty of Candour obligations.

5.3. The Good Place is fully committed to meeting the requirements of the Accessible Information Standard (AIS), as set out by NHS England. This means we will ensure that people with a disability, impairment, or sensory loss receive information and communication support that they can understand and use effectively. This may include large print, easy-read versions, audio formats, or the use of interpreters and communication aids. See our Accessible Information Standard (AIS) Policy and Procedure for further details.

5.4. We also comply with the Equality Act 2010 and are fully committed to promoting diversity, and human rights in all aspects of our service provision and employment practices. We are dedicated to ensuring that all individuals, including staff, service users, and stakeholders, are treated fairly, with dignity and respect, and without discrimination. We will also make reasonable adjustments so that no individual is treated less favourably when using our service. This includes supporting people with protected characteristics such as age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex, and sexual orientation. See our Equality, Diversity and Human Rights Policy and Procedure for further details.

6. Roles & Responsibilities

6.1. Responsibilities of the Registered Manager

6.1.1. The Registered Manager is responsible for ensuring compliance with the Duty of Candour. Their role includes:-

• a. Overseeing the reporting, management and review of notifiable safety incidents and other significant incidents.
• b. Ensuring that service users and their families or representatives are informed promptly, compassionately and appropriately when something has gone wrong.
• c. Ensuring that all relevant staff receive initial and refresher training and feel confident to comply with the Duty of Candour.
• d. Submitting incident notifications and reports to the Care Quality Commission (CQC) and other external bodies where required.
• e. Reviewing incidents, trends and learning to identify and implement service improvements, and evidencing this as part of our quality assurance and CQC assessments.
• f. Ensuring that evidence of Duty of Candour in practice (for example, examples of incidents, apologies, investigation reports, learning logs and changes to practice) is collated and available to demonstrate compliance during CQC inspections under the Single Assessment Framework.

6.2. Responsibilities of All Staff

6.2.1. All staff have a duty to:-

• a. Report incidents, near misses, errors and concerns immediately to their manager in line with our Management of Accidents, Incidents, and Near Misses Policy and Procedure.
• b. Be open and honest in their interactions with service users, families, colleagues and external professionals, particularly if something has gone wrong.
• c. Cooperate fully with any investigation or review of an incident, including providing factual accounts and relevant records.
• d. Ensure that any discussions held with people about incidents are documented accurately in care records and incident reports.
• e. Escalate any concerns that the Duty of Candour is not being followed to a senior manager, the Registered Manager or via the Raising Concerns, Freedom to Speak Up and Whistleblowing Policy and Procedure.
• f. Seek advice promptly from a supervisor or the Registered Manager if they are unsure whether an incident meets the threshold for a notifiable safety incident under Regulation 20, so that an appropriate decision can be made.

6.3. Responsibilities of Supervisors, Team Leaders and Senior Care Staff

6.3.1. Supervisors, team leaders and senior care staff are responsible for:-

• a. Ensuring that incidents reported to them are promptly escalated to the Registered Manager or on-call manager.
• b. Supporting staff to communicate openly and sensitively with people and their families after an incident, in line with this policy and any guidance from the Registered Manager.
• c. Checking that appropriate records have been completed and that any immediate safety actions have been taken.

6.4. Contacts for Reporting

6.4.1. Registered Manager (Dean Hill):-

• a. Email: [protected:adean][protected:athegoodplace.care]
• b. Telephone: 01283 296 337

6.4.2. Safeguarding Lead (Dean Hill):-

• a. Email: [protected:adean][protected:athegoodplace.care]
• b. Telephone: 01283 296 337

6.4.3. Failure to comply with this policy may result in disciplinary action, as transparency and honesty are fundamental values of our organisation.

7. Definitions

7.1. Duty of Candour – The Duty of Candour is a legal obligation on health and social care providers to act in an open and transparent way with people who use their services when things go wrong in the provision of a regulated activity and the person suffers, or may suffer, certain types of harm or death as a result.

7.2. Notifiable Safety Incident – A notifiable safety incident is an unintended or unexpected incident that occurs in the provision of a regulated activity and, in the reasonable opinion of a health or social care professional, has resulted in any of the following outcomes (as defined in Regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014):-

• a.  Death of the service user, where the death relates directly to the incident rather than to the natural course of the person’s illness or underlying condition.
• b.  Severe harm – a permanent lessening of bodily, sensory, motor, physiologic or intellectual functions (including removal of the wrong limb or organ or brain damage) which is related directly to the incident and not related to the natural course of the person’s illness or underlying condition.
• c. Moderate harm – harm that requires a moderate increase in treatment and causes significant but not permanent harm, or a prolonged period of pain or psychological harm.
• d. Prolonged psychological harm – psychological harm which a person has experienced, or is likely to experience, for a continuous period of at least 28 days.

8. Procedure for Managing a Notifiable Safety Incident

8.1. When a notifiable safety incident occurs, The Good Place follows a structured process to ensure transparency and compliance with the Duty of Candour and to align with our Management of Accidents, Incidents, and Near Misses Policy and Procedure, Safeguarding Adults Policy and Procedure, Complaints Policy and Procedure and Risk Management Policy and Procedure.

8.2. Step 1: Immediate Notification

8.2.1. As soon as a notifiable safety incident is identified, the affected service user (or their representative) must be informed as soon as reasonably practicable. This discussion should normally be held in person by the Registered Manager or a suitably senior and knowledgeable member of staff and must be conducted with compassion, sensitivity and in a way the person can understand. Where an in-person discussion is not possible, we will use the most appropriate alternative (for example, telephone or video call) and document the reasons.

8.2.2. We will also ensure that any immediate safeguarding or clinical interventions required to protect the person or others are taken without delay and that relevant professionals (for example, GP, community nurse, emergency services, safeguarding team) are contacted as appropriate.

8.3. Step 2: Providing a Clear Explanation

8.3.1. The following information must be shared with the service user and/ or their representative, based on the facts known at the time:-

• a.  A factual account of what is known to have happened, without speculation or blame.
• b.  The immediate actions taken to ensure the safety and wellbeing of the service user.
• c.  The known or potential impact of the incident on their health and well-being, using clear, jargon-free language.
• d.  The steps being taken to investigate and prevent recurrence, including how and when they will be updated as further information becomes available.

8.3.2. If further information becomes available during an investigation, we will provide the service user and/or their representative with updated explanations as soon as reasonably practicable.

8.3.3. If the service user lacks capacity, information should be shared with their legally appointed representative (such as an attorney under a Lasting Power of Attorney, deputy appointed by the Court of Protection, or other person acting in their best interests) in line with the Mental Capacity Act 2005. Where appropriate, we will support the involvement of an independent advocate or IMCA.

8.3.4. Where the incident involves more than one organisation, we will cooperate with other providers to agree who will lead on Duty of Candour communication. However, we will always make sure that the service user and/or their representative receive clear information from us about our role and are not left without an explanation.

8.4. Step 3: Offering a Meaningful Apology

8.4.1. A sincere and genuine apology must be provided both verbally and in writing. In line with Regulation 20 and national guidance, an apology is an expression of sorrow or regret and is not, in itself, an admission of legal liability. The apology should acknowledge the incident and the impact on the person, and reassure the service user that we are taking the matter seriously and will learn from it.

8.5. Step 4: Documenting the Incident

8.5.1. A detailed written record of the incident and our Duty of Candour actions must be kept, including:-

• a. The nature of the incident, when and where it occurred, and what went wrong.
• b. The date, time, method and content of each communication with the service user and/or their representative.
• c. The name and role of the person(s) who communicated with them.
• d. A copy of the written apology and any follow-up correspondence.
• e. Any actions taken to address and mitigate the incident, including immediate safety measures.
• f. Outcomes of any investigation, lessons learned, and plans for future prevention and improvement.

8.5.2. These records must be stored securely in line with our Records Management and Confidentiality policies and be available for CQC inspection.

8.6. Step 5: Reporting the Incident to CQC

8.6.1. Following the initial verbal notification required under Regulation 20, we will send a written follow-up to the service user and/ or their representative as soon as reasonably practicable. This will include:-

• a. A summary of what is known about the incident.
• b. An apology.
• c. Information about the investigation process, expected timescales and a named contact person.
• d. Details of any immediate actions taken to reduce the risk of harm.
• e. How they can raise further questions, concerns or complaints and how they can access support or advocacy if needed.

8.6.2. We will keep the person and/or their representative updated at appropriate intervals, particularly at key points in any investigation or review, and will share the findings and learning in a way that is clear and understandable.

8.7. Step 6: Statutory Notifications and External Reporting

8.7.1. If the incident meets the criteria for a notifiable safety incident under Regulation 20, the Registered Manager must notify the Care Quality Commission (CQC) using the appropriate notification form, within the required timeframe.

8.7.2. In addition, we will consider whether the incident needs to be reported to other bodies such as the local authority safeguarding team, commissioners, the Health and Safety Executive, the police or the coroner, in line with relevant guidance and our Safeguarding Adults Policy and Procedure and Management of Accidents, Incidents, and Near Misses Policy and Procedure.

8.8. Step 7: Learning and Improving

8.8.1. A full internal investigation or review must take place, proportionate to the seriousness of the incident, to determine root causes and contributory factors.

8.8.2. We will develop and implement an action plan to address identified issues. This may include changes in policies, procedures, care plans, training, supervision, staffing levels or equipment.

8.8.3. Learning from incidents and Duty of Candour processes will be shared appropriately with staff through team meetings, supervision and training, and where possible with people who use our service and their families in an anonymised and sensitive way.

8.8.4. We will monitor the implementation and effectiveness of any actions through our quality assurance processes and governance arrangements, and we will use this learning as evidence for CQC under the Single Assessment Framework.

9. Training and Awareness

9.1. All staff must receive comprehensive Duty of Candour training as part of their induction and as part of regular refresher training (at least every 3 years, or sooner if there are significant changes in legislation or guidance). Training will cover:-

• a. The legal and ethical responsibilities under the Duty of Candour.
• b. How to communicate effectively with service users and families after an incident.
• c. The importance of offering a meaningful apology.
• d. The process for reporting and documenting incidents.

9.2. Managers must also receive specific training on how to lead open conversations and manage serious incidents in a transparent manner.

9.3. We will assess staff understanding of the Duty of Candour, for example through supervision, reflective discussions, incident debriefs or knowledge checks, and provide additional support and training where gaps are identified.

9.4. Training and learning activities relating to Duty of Candour will be logged (for example, attendance records, reflective learning notes and scenarios discussed) so that we can evidence staff competence and our open and honest culture under the CQC Single Assessment Framework.

10. Compliance and Monitoring

10.1. To ensure that this policy is followed consistently, the Registered Manager will:-

• a. Conduct regular audits of incident reports, notifications and Duty of Candour documentation, including timeliness and quality of communication.
• b. Analyse trends and themes from incidents and Duty of Candour cases to identify areas for improvement and share learning with staff.
• c. Collect feedback from service users, families and staff to assess the effectiveness of our open and honest culture and communication after incidents.
• d. Use the findings from audits, feedback and reviews as evidence for our CQC Single Assessment Framework submissions and ongoing quality improvement plans.
• e. Maintain anonymised examples of Duty of Candour cases, including what happened, how we communicated with people, what we learnt and what changed as a result, so that we can demonstrate good practice and learning.
• f. Cross‑reference Duty of Candour findings with other sources of insight such as complaints, safeguarding alerts, incidents, compliments and staff feedback to identify any themes or patterns.

10.2. Any failure to adhere to the Duty of Candour requirements will be addressed through additional training, supervision and, if necessary, disciplinary action, in line with our HR policies. Serious or repeated failures may be escalated to senior leadership, commissioners and/ or the CQC as appropriate.

10.3. This policy and our Duty of Candour processes will be reviewed following any significant changes in legislation or national guidance, relevant learning from safeguarding reviews, coroners’ reports, serious incident reviews, or specific feedback from CQC, to ensure that our approach remains current and effective.