Closed cultures in social care: Guidance and questions to ask

• Family and friends
• Independent advocates (Care Act advocates, independent mental capacity advocates (IMCAs) – tend to visit for specific tasks, such as needs assessments or reviews, safeguarding enquiries, a proposed change of accommodation, serious medical treatment, some other reviews if referred by health, including continuing healthcare (CHC) or reviews of mental health aftercare under s117 of the Mental Health Act)
• Relevant Person’s Representatives (RPRs), whether family or friends, or paid advocates, who provide regular contact with anybody who is subject to a Deprivation of Liberty Safeguards (DoLS) authorisation at a care home or hospital
• Rule 1.2 representatives (ongoing regular observation for a deprivation of liberty (DoL) authorised by the Court of Protection – at settings other than care homes or hospitals – including supported housing, extra care, ordinary housing/own home with domiciliary care) 
• CQC inspectors
• Ofsted (in the case of education providers)
• Contract monitoring staff
• Primary and community health services, such as general practitioners (GPs), nurses, therapists (including speech and language therapists, physiotherapists, occupational therapists), ambulance crews, opticians, audiologists, dieticians, podiatrists, other health professionals, such as members of community learning disability teams and community mental health teams
• Education services
• Faith leaders 
• Best interests assessors and Deprivation of Liberty Safeguards (DoLS) Mental Health Assessors (for those who lack capacity and need to be deprived of their liberty – one-off prior to authorisation)
• Social work practitioners when reviews are due, when needs change and re-assessment is required, or when there may be a safeguarding concern
• Visiting hairdressers, guests providing activities, such as performers, people who bring animals in such as therapy dogs, small animals, horses or llamas

Guidance on professional curiosity such as the Norfolk Safeguarding Adults Board - Professional curiosity guidance encourages practitioners to “Acknowledge ‘gut feelings’, share these with other professionals, and look for evidence” and to “Consider how you can articulate ‘intuition’ into an evidenced, professional view and discuss ‘gut feelings’ with other professionals.”

The Association of Directors of Adult Social Services (ADASS) ADASS advice note 'Safeguarding adults during the Covid pandemic' (2021) recognised the risks associated with closed environments during COVID, but these are not limited to pandemic circumstances. The ADASS 'Safeguarding people in ‘closed’ environments checklist' suggests that past risk can be the best indicator of future risk, and that if you have had concerns about a particular setting in the past, you should keep those establishments on your radar.

Think about what alerted commissioners to concerns previously and what might be signs of those risks continuing or reoccurring.

It is also important to highlight when you have heard nothing from, or about, a service for a long time.  It may be that everything is going well, but it may be good to check in with a “silent service”, from time to time, and not to assume that “no news” is always “good news”.  A lack of any information, notifications or contact might be an indication that there is a problem.

Whilst we routinely think of closed cultures as being in institutions and therefore immediately think of care homes or hospitals, all workplaces have a workplace culture. It is possible for closed cultures to develop in other models of social care, including supported living, day activity services, shared lives.

It is also important to recognise that some adult social care services are not regulated or inspected by CQC. In such situations, regular external oversight will not involve CQC and will be dependent on other visitors. Skills for Care’s 'Positive workplace culture toolkit' provides links to a pdf toolkit and a helpful webinar recording (56 minutes) that takes the audience through the principles of the toolkit.

The toolkit supports managers to prioritise a positive workplace culture in adult social care settings, supporting them to recognise potential problems and recommending a number of techniques to set up a positive workplace culture, or to enable a shift towards a more positive workplace culture, if required.  The video includes examples of how these approaches are used in a home care agency.

Despite the best strategic commissioning approaches, there are sometimes situations when a person has to move from one setting to another, occasionally at short notice. In such situations, especially in an emergency, it can be such a relief to find a service that may be able offer support to the person, that practitioners, commissioners and even family may find themselves accepting the option without giving full consideration to the risk of closed cultures.

Options may be considered to:

• Take up a vacancy in an existing service
• Seek an out-of-area solution, as there may be nothing available locally, and there may not be enough time to set something up locally.

The guidance in this document is just as relevant to these situations and should be considered at the earliest possible time.

Quality Matters (2019) recognised that commissioning for quality means that commissioners do not fund new services in places that have been identified by the Care Quality Commission as inadequate or failing to meet people’s needs. Where such services are already funded, they are reviewed. The Quality Matters partners, at that time, committed to “support commissioners not to fund new placements or services that are rated as inadequate or where there are justified safeguarding embargoes” and said that “commissioners will identify quality concerns and avoid commissioning at speed.”

It is, however recognised that when an existing care and support arrangement breaks down, commissioning at speed can be required. An initial review of such a service should be completed to consider the risks to the person, including the risk of a closed culture, as soon as possible. Concerns about the possible detrimental impact of multiple moves should always be balanced by the need to safeguard the person, and should not be used to justify ignoring the impact of an existing closed culture or risk of a closed culture developing.

When trying to find new support for a person where it has been difficult to source support, for whatever reason, commissioners and practitioners may, together with the person and their family or advocate, find it useful to co-produce a series of questions to ask, to satisfy themselves about the provider’s ability to meet the needs of the person, and resist the temptation of accepting an offer, purely on the grounds that they can offer support immediately.

When a person’s current arrangements are not meeting their needs, but new support is not required in an emergency, commissioners may be able to consider developing new bespoke support.

Our Bespoke support for people with a learning disability and autistic people evaluated the impact of a range of services that have been developed in this way and used a set of ten outcome descriptors to support the evaluation, based on previously co-produced pieces of work such as the Good Lives Framework (Learning Disability England) and Making it Real (Think Local, Act Personal (TLAP)). The National Development Team for inclusion (NDTi) have also developed web-based resources to support the development of what they refer to as “small supports”.

Whilst such services take a person-centred, co-produced approach to the development of the support for each person, championing human rights, the resulting service often involves a team of carers working with a person, often in ordinary housing.

Whilst many people will be supported to go out and about where they live, there is a risk that a smaller range of people will visit them at home. If the support is funded using an individual service fund or direct payments, it may be decided to use personal assistants rather than home care, and the support may therefore not be regulated or inspected by CQC.

Whilst the value-base associated with this model of support should mitigate against closed cultures, commissioners and practitioners should not ignore the possibility. This guidance and the questions in this document are therefore just as relevant to consider. It will be important to consider who has oversight of such services and who manages the risks.

When working with a setting that has people living there, where different local authorities have commissioned the support, it is good practice for the placing authorities to notify host authority commissioners of the arrangements (see ADASS advice note 'Commissioning out of area care and support services', 2018).

Commissioners from placing authorities should notify the host authority of any concerns with a provider, even if the host authority does not commission services there.

There may be a need for a host authority to work with a range of placing authorities and CQC, if there are concerns about a service or the organisation that runs the service, or if safeguarding concerns are raised that involve a number of people.

It is important to recognise the role that speaking up plays for all of us, including both people who draw on a service, and also others who may speak up about a concern, including staff who support the person.

Everybody should be encouraged to speak up if they witness something they are uncomfortable about. Employers’ policies and procedures should require this, and staff training should reinforce this expectation. The importance of listening to everyone in these situations should be emphasised.

Staff should be informed that there is support for whistleblowers and how to access that support.

People who draw on services or support should be reassured that independent support is available if they wish to raise a concern or complaint, and how to access that support.

There are a number of documents, that have been co-produced and further developed with people with lived experience, that describe positive frameworks and give examples of what people with a learning disability and autistic people think support should be like.

These include:

• The Reach standards, published by Paradigm
• The Good Lives framework, published by Learning Disability England
• The Making It Real I and we statements, published by Think Local, Act Personal (TLAP)
• Our Better Lives framework
• The 'What good looks like' co-produced report, published by the Local Government Association
• Gloriously Ordinary Lives and the associated tests

Commissioners may find these documents and frameworks useful to use with people with lived experience, when developing specifications for new services or to review existing services.

When experiencing closed cultures and associated poor care or support, it can clearly be harmful for people who draw on that care or support. Another factor to consider is that in the face of negative experience, it can be demoralising for staff and others. They can become discouraged by, or acclimatised to, poor services and put up with them, feeling powerless to achieve any improvement. This can include commissioners. It can lead them to lower their expectations.

Managers in commissioning and operational services can support staff to maintain their hopes and aspirations for the people supported, by providing regular opportunities for peer mentoring, individual supervision, sharing of good practice (conferences, webinars or training), and by looking out for, and responding appropriately to, stress associated with secondary trauma or compassion fatigue.

Throughout all stages of the commissioning cycle, commissioners will work alongside partners – other commissioners and CQC – as well as providers, to check for the risk of closed cultures and to prevent them from emerging or to replace them, where they emerge. It will be important for partners to work together, on an ongoing basis, to consider the following points:

• Can we improve how we work together to support this provider to improve?
• How will we work with other commissioners, such as health commissioners and children’s commissioners?  How will we involve safeguarding and complaints colleagues to ensure we triangulate information on both concerns and on improvement?
• Will we each measure improvement in the same matters, or take responsibility for measuring improvement in different matters?
• How will we ensure we are not adding unnecessary workload, requiring providers to double-do accountability tasks, which may impact on how quickly they can improve?   
• How will we communicate about improvements, including whether they are achieved or not achieved in the required timeframe? Have we made this clear to the provider and are you confident that they understand?

• Am I up-to-date with what is considered good or bad by people with a learning disability and autistic people?
• How will I seek the views of people with a learning disability and autistic people, their families and representatives, to inform the specification?
• Am I familiar with the content of the Oliver McGowan mandatory training? How much weight do we want to give in our specification to recognising the risk of, and taking action to prevent or change, closed cultures?
• Are we confident that we understand, and can describe, what a closed culture is?
• Can we clearly describe the positive cultures that we require?
• Do we emphasise the requirement for positive cultures in our specifications for all models of social care support (not just in specifications for care homes)?

This is the time when we write down what we expect from the service. From your experience, what are the most important things that should be included in the specification, to help us to recognise providers who don’t understand the risk of closed cultures, and who are unlikely to respond appropriately to prevent or deal with closed cultures?

From your experience, what are the most important things that should be included in the specification, to help us to recognise providers who don’t understand the risk of closed cultures, and who are unlikely to respond appropriately to prevent or deal with closed cultures?

What is crucial to include in the specification to ensure that providers will be able to describe how you will prevent the development of closed cultures or effect a change to more positive cultures if they arise?

From your experience, what are the most important things that should be included in the specification, to help us to recognise providers who don’t understand the risk of closed cultures, and who are unlikely to respond appropriately to prevent or deal with closed cultures?

• How will we ask providers to demonstrate their understanding of closed cultures, their recognition of the risk of closed cultures developing and their ability to prevent this or to change cultures from closed to more positive cultures?
• How will we judge the answers to these questions? 
• How will we triangulate the answers to the questions with data and information we have from other sources, such as complaints, safeguarding, and feedback from local quality checkers, people who draw on the service, their family and representatives, and other professionals and practitioners? 
• With reference to evaluating the tender responses, have we included all the questions we require, to elicit all the information we will require to make a judgement about the risk of closed cultures existing or emerging?
• Assuming that people with lived experience and their families or representatives will be involved in the evaluation of tenders, have we asked questions and sought responses in a way that will enable people who draw on the services and their family or other representatives to form a view about each tender response?

This is the time when we invite providers to tell us about their service and how they would meet the specification and we tell them what information we want them to provide to show us how they would provide the service.

• What do we need to say in the invitation to make sure providers know how to supply information in a way that will help you to decide if they will be a good provider of this service?
• How should providers reassure you that they understand the problems with closed cultures and know how to deal this this issue? 
• How would you be able to help us decide which provider is likely to be the best one for the contract? What support will you need?

• How should providers reassure you that they understand the problems with closed cultures and know how to deal this this issue? 
• How would you be able to help us decide which provider is likely to be the best one for the contract?
• Would you need support and if so, what support would you need?

When responding to tenders:

• How do you ensure that staff understand and apply equalities and human rights legislation?
• What challenges do you face that may pose a risk to a positive workplace culture?
• Can you describe what a closed culture is? Please do so.
• What methods do you employ to prevent the development of a closed culture?
• Are you familiar with guidance from Skills for Care or others on preventing closed cultures, and on developing positive workplace cultures? How do you use this?
• Are your staff all aware of the Oliver McGowan mandatory training for people who work with people with a learning disability and autistic people? Have they all been given the opportunity to undertake the training that is available (whether online or face-to-face)?
• Is whistleblowing supported and an expected norm in your organisation? 
• How do you help staff who wish to raise concerns about a particular environment to do so safely?
• How do you provide information to all staff about whistleblowing as part of induction, and how is this updated annually?
• As staff members, what is your experience of using the whistleblowing procedure? Have you experienced repercussions or bullying, after raising concerns?

• Are people at the setting highly dependent on staff for their basic needs?
• Are people at the setting less able than others to speak up for themselves without good support?
• Are restrictive practices used by staff, such as people being prevented from doing what they want to do or being made to do things they do not wish to do?  How are these reviewed?
• Do people remain at the setting for long periods (many months or years)?

• Does the service sometimes run without a manager or leader available /onsite (reasons for this may include frequent changes in management and management responsibility for more than one site)?
• Does the workforce comprise members of staff who are either related or friends, causing ‘cliques' to form?
• Is there a lack of openness and transparency between managers, staff, people drawing on the service and external professionals and organisations?
• Do managers lead by example?
• Is governance weak? such as a lack of accountability, or arbitrary policy making, and staff not being sure what is required when things go wrong. 

• Is there a high turnover of staff?
• Are agency staff relied on? If agency staff are used, how are they used, booked, inducted, supported and how are concerns raised?
• Are there consistently staff shortages?
• Is there a lack of suitable induction, training, monitoring and supervision of staff (both in the sense of the observation and monitoring of practice and also separately scheduled opportunities for reflection and discussion to improve practice?

• Is the setting in an isolated location resulting in people who live there having limited access to community services and facilities and limited opportunities for friends and family to visit? 
• If the setting is in an isolated location, are there any issues affecting out-of-area commissioners’ ability to review the care and support provided?
• Is the provider operating at scale and/or nationwide with regional managers covering large areas?
• Is the provider organisation marketing its services as specialist services, willing to take people from all over the country?

For each provider being evaluated, do you believe that the provider has satisfactorily demonstrated that they:

• Understand what closed cultures are?
• Understand the risks associated with closed cultures for people who draw on their services?
• Can recognise signs of a developing closed culture?
• Know how to respond, to prevent the development of a closed culture, or to change the culture so that it is no longer closed?

With specific reference to external oversight, the following questions may be useful:

• Does the service support a number of people that have come there from a long way away?
• Who makes decisions to accept people at a long distance from home?  How much does the provider encourage or support this?
• How often are people placed in an emergency? What processes does the provider have when this happens, to ensure a review happens quickly?
• Does the provider refuse to take people from far away?  Does the provider point out to commissioners that the distance may cause issues for the maintenance of the person’s relationships and quality of life?
• Is the setting cut off, separate or distinct from the rest of the community in some way, other than being in an isolated location?

This is the stage when we read everything the providers have sent us to understand their approach to the services we need. We may meet some of the providers to interview them, if we think that will help us decide which provider (or providers, if we need more than one) are good enough to be offered a contract. If there are more than we need, or more than we can afford, we may need to choose which are the best.

• Is it clear how you will be involved in the process to decide which provider (or providers) are good enough and which are the best for the contract?
• Is there any support you need that we may have not thought of, yet?

• Is it clear how you will be involved in the process to decide which provider (or providers) are good enough and which are the best for the contract?
• Is there any support you need that we may have not thought of, yet?

• During contract negotiations have you made it clear that you will monitor the culture of the organisation and the services they provide, and in particular that you will check for an increased risk of closed cultures developing?
• Have you explained what action you will take if a closed culture emerges?

• Are you clear from the contract and any contract negotiation discussions with the commissioners how they will continue monitoring the culture of your organisation and services and what action they will take if a closed culture emerges?
• Are you clear how you will make sure that all staff are aware of this approach?
• As staff, do you feel confident that you know how the service will be monitored to check for the risk of closed cultures developing?

• Do you have evidence that people drawing on the service experience poor care or support, including unlawful restrictions?
• Do you have any concerns about what you see, hear or smell? This could include concerns about cleanliness, damp, support with personal hygiene and oral health. What does it smell like? Does it smell of urine, faeces, chemicals?
• If needed, is there adequate support for people to maintain personal hygiene?
• Is the accommodation dirty? Is there a failure to ensure the environment is healthy and safe (including the safe storage and administration of medication, and meeting health and safety requirements)?
• Are the rooms in a poor state of repair or poorly furnished?
• Are basic needs being met?
• Are there concerns about the quality of basic care and the environment?
• What is the quality of the accommodation like?
• Are there concerns about the way the service or support is planned and delivered?
• Is the service clear about the kind of support they are able to deliver?
• Are the people who live together a compatible group? Do they get on and have they chosen to live together? If not, are they happy to live together?
• Are there concerns about anybody’s wellbeing? Are any concerns communicated by changed behaviours?
• Is the language staff use respectful?
• Have the staff team developed their own language or words they use? Is it nice and helpful or unhelpful?
• What do staff call people (service users, clients, by their names, or other)?
• Do staff use medical or service jargon when talking to people? Do they use language that helps understanding?
• Are staff cooperative, open, transparent, and keen to answer questions?
• Do staff volunteer information and/or ask the visitor questions and include the person where possible?
• Are restrictions, possibly including restraint, long-term segregation and prolonged seclusion, being imposed on people without an assessment of need, legal authority/legitimate aim? Is there a failure to review these and ease them over time?
• If a Deprivation of Liberty Safeguards (DoLS) authorisation or a community deprivation of liberty court order is in place, are staff clear about any restrictions the authorisation or order allows? Is there any evidence of disproportionate restrictions being used?
• Are any blanket restrictions in place? Examples may include a set bed-time for everyone, or the kitchen being closed to everyone so they can’t make a drink or some toast when they want.
• Does the provider used locked doors? Why is this? Does it impact on everyone, as a blanket restriction? Is there risk assessment and care and support plan for each person that it affects? Does the person have capacity to consent to the locked door being used? Do people have their own keys that they can physically use to unlock doors, such as their bedroom door or the kitchen door? If keypads or keysafes are used, are some people unable to use these? 
• Are restrictions used that are unnecessary and not the least restrictive option possible to keep a person safe from harm?
• Is surveillance used, such as closed-circuit television (CCTV), without ensuring that this is done in a way that protects people's privacy and human rights?
• Are people asked to go to their rooms or another area and then prevented from leaving?
• Does the way premises are being used lead to increased restriction or lack of choice for people?
• Is there a poor application or understanding of the Mental Capacity Act (MCA) 2005 and Mental Health Act (MHA) 1983, including not following the codes of practice for the Mental Capacity Act, the Deprivation of Liberty Safeguards (DoLS) and the Mental Health Act?
• Are there any concerns about medicines management, including inappropriate use of medicines to restrain or control behaviour?
• Are people safeguarded against discrimination, harm and abuse (for example, are there any specific concerns raised in relation to this or a high or increasing number of safeguarding incidents, complaints, poor feedback through surveys, education, health and care plans or other notifications)?
• Is information about rights provided to people and their families when they first arrive, as well as at regular intervals during their stay?
• Are agreed staffing levels being provided? 
• Are agreed programmes or plans being carried out?
• Do members of staff and managers carry out recommendations made by external professionals?
• Is recommended specialist equipment provided and are people supported to use such equipment effectively and safely?
• Is there a view that the service may be unsuitable for one or more people, but that no better option is available? If so, how is that being managed?
• Do members of staff or others believe that this is the only place that the person (or people) could live? Why? Do they appear unwilling to consider other options?
• Is there pressure to make the service work because of a perceived or actual lack of alternative provision?
• Is the service unable to provide personal support by workers of the same sex where this is required?
• Have people with a history of abusing been placed alongside other people who may be unable to protect themselves, due to their support needs?
• Have people of diverse abilities or with a wide variety of support needs been placed together in the absence of strong friendships?
• Do the majority of members of staff have the specialist skills needed to support the people who need that support?
• Does the design of the building prevent or hinder members of staff monitoring the safety of individual people?
• Are short-break services being offered alongside long-term services (so it may feel like strangers are present in a person’s home)?
• Are individual people able or unable to use equipment provided to help them stay safe?
• If the service offers accommodation, do lots of people come in and out of the accommodation, who may be connected to the organisation but are not involved in the care or support of people who live there (for example, the accommodation may be attached to an office and office staff may come through rooms inappropriately)?
• Is there poor or inadequate support for people with health problems, who become ill, or who have additional needs (such sensory impairments)?
• Is the dignity of people being promoted and supported?
• Are people supported to do the activities they enjoy?
• Are people given support to change behaviours that are considered by others to be inappropriate or harmful? Do staff try to understand what the person is communicating by these behaviours?
• Is there a lack of care of people’s personal possessions, clothing or specialist equipment? Is accountability regarding individual people’s money adequate? 
• Are essential clinical records being kept? 
• Do any people engage in self-harm?
• Do any people engage in inappropriate sexualised behaviours?
• Do any people have a number of physical injuries?
• Do measures which were introduced to protect people make a difference?
• Does anybody show signs of fear, or talk about not feeling safe?
• Are there any people who control, bully or harm others? 
• Are there any people who might be abusing others and who don’t understand or respect the idea of consent?
• Are there any people who talk about boyfriends/girlfriends or the possibility of pregnancy, when they may need support to understand positive relationships, sexual relationships and the risks associated with this, including safe sex, pregnancy and childbirth?
• Are there people who don’t understand what abuse is and who don’t realise they should not be abused?

• Is the manager aware of the philosophy of the provider organisation? Does the manager work in a way that reflects this philosophy?
• Does the philosophy include important ideas about how to support people, such as giving choice, keeping safe and being independent?  
• Does the manager behave in a way that is consistent with the values and ideas included in the service’s philosophy (this may also be called a Charter or Statement of Values)? 
• If the service is part of a wider organisation, does the manager receive enough support from senior managers within the wider organisation?
• Are registered managers or other managers in the organisation doing, or not doing anything that gives you cause for concern? 
• Does the governance of the service appear clear and is it followed by staff and managers?
• Is the manager visible, or do they stay in an office, behind closed doors? Is support from managers or more experienced staff available when needed?
• Are staff supported and encouraged to 'speak out' and raise concerns or are staff actively discouraged?  Are staff afraid to do so (this may be due to ineffective whistleblowing policies, or a lack of support and guidance for staff)
• Is the manager monitoring and addressing issues raised by staff, people drawing on the service, relatives or other visitors, including external agencies and professionals?
• Is the manager failing to engage and respond to recommendations?
• Are there any allegations of cover-ups
• Do managers use reflective practice, such as the 'five whys' when things go wrong, and use such incidents as a learning opportunity (the 'five why’s' is the practice of asking 'why' to try and understand why the presenting issue is happening, and to continue to ask 'why' in response to each reply, up to five times)? 
• Are there differing views between managers and staff about how people are being or should be supported?
• Is there high use of unqualified staff, agency staff and vacant posts?
• Are there staff shortages or high levels of staff sickness?
• Is staff morale low? Are there members of staff who feel “burned out”? 
• Are there high levels of staff turnover?
• If people don’t tend to stay, do managers know why not? 
• Are there frequent changes of key workers?
• Do staff employed for auxiliary or administrative purposes (such as domestic or office staff) take responsibility for the care and support of people or help those who are distressed or angry, where there should clearly be a member of care and support staff involved?
• Do some members of staff lack experience and skills in supporting people with a learning disability or autistic people?
• Have most of the staff group only worked in this setting or organisation, or with this group of people with a learning disability or autistic people (such as, a staff group that moved from hospital to a care home with the people they support)?
• Who are the “long-timers” among the staff, how are they related to one another, and are they in positions of power or cultural influence? 
• How are people recruited and trained?
• Are there high levels of turnover of the people who live there? If so, why is this?
• Is it possible to talk to professionals or family who have moved people, or supported a person who left?
• Are notifications to CQC poorly completed?  Is there a lack of detail and are there concerns about the tone or language used?
• Are there concerns about the condition and suitability of the physical environment that people are living in, that are not being adequately addressed in a timely way? 
• Are there any allegations of staff bullying?
• Do staff work excessively long hours or overtime?
• Do shift patterns mean that the same people are always working together?
• Has there been a failure to respond to any negative impact of a health protection issue, such as an outbreak of COVID or other infection prevention and control concern?
• What systems or approaches are used by managers or owners to maintain an overview of how the care and support is provided?
• Is there a ‘whole home’ or ‘whole system’ perspective taken to identify gaps in intelligence?
• Does the manager review problems to prevent harm?
• Who has control over the person’s life? What types of control? Who makes decisions and how are decisions made?
• Is there evidence that the manager either can’t, or doesn’t want to, make decisions or take responsibility for things?
• Does the manager make sure that members of staff are doing their job properly?
• Does the manager make sure that staff meetings and supervision take place?
• Has the manager explained to members of staff exactly what they are there to do as members of staff?
• Does the manager have enough experience of working with people with a learning disability and autistic people and an understanding of the care and support needs of people with a learning disability and autistic people?
• Is there always a manager available to contact or to talk to?
• Does the manager appear to be unable to change the way a group of strong/powerful members of staff are working?
• Does the manager find it hard to listen to ideas and suggestions about different ways of working, or reluctant to talk about these?
• Does the registered manager and other managers in the organisation support members of staff who complain or act as whistleblowers?
• Does the manager or organisation tell council and health commissioners if the service cannot meet an individual’s needs?

• Are there any concerns about staff skills, knowledge and practice?
• Do staff demonstrate an understanding and commitment to diversity,  equalities and human rights legislation? Do they know what protected characteristics are and ensure that people do not experience discrimination due to their protected characteristics?
• Is there a lack of suitable recruitment and induction?
• Is there a high use of poorly inducted agency staff or locums who do not know people's needs?
• Is there a failure to provide regular, good quality staff supervision and time for debriefs and reflective practice?
• Is there a lack of monitoring of, and challenge to, poor practice?
• Are staff being given training that enables them to meet the needs of, and to effectively safeguard, people who draw on the service (for example, is there a lack of training about the needs of autistic people or people with a learning disability)?
• Are staff doing, or not doing, anything that gives you cause for concern (note, not just care staff but also, for example, cleaners, catering staff, administrative staff and managers)?
• Are there concerns about a lack of candour?  Do staff admit when they make mistakes and apologise? Do they try and act differently next time?
• Are you concerned about information being hidden or misreported by staff? 
• Is there evidence of learning from experience and errors or incidents being identified and learnt from, or are problems ‘airbrushed’ out of existence?
• How are complaints and concerns from families and friends dealt with? Are they seen as a learning and continuous improvement opportunity?
• How are practice concerns and learning opportunities communicated among staff?
• Do members of staff understand what is involved in working as a support worker for people with a learning disability and autistic people?
• Do key workers understand their roles and responsibilities as a key worker?
• Do members of staff understand what it means to have a learning disability or to be autistic and how a learning disability or being autistic may affect a person’s responses to their surroundings?
• Do members of staff understand how important events in peoples’ lives might affect their behaviour (these events might include past abuse, trauma, living in an institution, making a new relationship or losing an important relationship)?
• Do members of staff support a person’s responses to situations, including if they find them challenging, in a safe, professional and dignified way?
• Is restraint used frequently and as a first option before other approaches are tried? Are more subtle forms of restrictive practice used that prevent someone doing what they want to, or make them do something they don’t want to, such as making someone use a wheelchair when they are willing and able to walk?
• Do members of staff touch people in inappropriate ways (this might be over rough or too intimate)?
• Do members of staff lack skills in communicating with people and in interpreting their communication, including how they respond to situations?
• Do members of staff communicate with people in ways which suggest a lack of warmth, friendliness or dignity?
• Do members of staff tease or play jokes on people or treat serious incidents as a joke?
• Do staff belittle, exclude or taunt people?
• Have members of staff had training in behaviour management or positive behaviour support or something similar?
• Do members of staff lack training and awareness about what abuse is, signs of abuse and the actions to be taken in the event of suspected or actual abuse?
• Do members of staff lack experience of working with different groups of people with a learning disability or autistic people?
• Are people helped to access their money when they need or want it? 
• Are members of staff clear about the appropriate use of a person’s money
• Do members of staff lack awareness of sources of support and the roles of other professionals and organisations?
• If people need others to undertake non-care tasks (such as cleaning, phone calls and other administrative tasks), as part of their support, do staff treat these tasks as more important than spending time with the person or supporting them with other tasks?
• Do members of staff appear to lack motivation?
• Are members of staff reluctant to change their practice?
• Do members of staff appear to perceive a person’s “behaviour” as a problem, rather than exploring the possible causes of that response?
• Are plans made for people based on what is practical for the organisation rather than people’s needs and wishes?
• Do members of staff involve people in decisions? Do members of staff give only limited options to people they support? Are choices undermined or disrespected?
• Do staff ever "use choice as a weapon"? For example, they might say, “they chose to stay in bed all day, that’s their choice, so we haven’t encouraged them to do any activities or to have contact with other people.”
• Do staff “assume precedence” over family?  For example, they may believe that they know what’s best for the person better than family, so they may dismiss the family’s opinions.
• Do members of staff treat people as if they ‘belong’ to them or as if they know them best, when there may be others who know the person better?
• Are individuals punished, threatened or ignored for lengthy periods of time? Do staff realise that this amounts to psychological restraint and unacceptable restrictive practice?
• Are individuals locked in or out of rooms or is there confusion about when doors should be locked to preserve a person’s safety?
• Are people treated respectfully taking into account their individual likes and dislikes?
• Is the organisation of the support influenced more by staff members’ needs or wishes than those of the people who live there?
• Are any members of staff or groups of staff very controlling of people? Do they raise their voice or shout at people?  Do they strongly influence the way things happen in the service?  Do they appear to be over-controlling or coercive?
• Is there a strong staff clique and/or staff friendships and loyalties which extend beyond the workplace (for example, belonging to a particular club or society)?
• Do established members of staff intimidate, bully or ‘set up’ newer members of staff?
• Are people who challenge what goes on or report their concerns cut off or bullied?
• Do members of staff know what is okay in relationships between staff and the people they support? Do they flirt or pretend to be the person’s girlfriend or boyfriend?
• Do members of staff respect confidentiality and keep things confidential?
• Do members of staff get too involved with people who live in the home (this might include treating people as family or doing things that may make some people feel uncomfortable)?
• Do members of staff appear to develop inappropriate levels of intimacy or ‘groom’ people with care and support needs (grooming is the process some abusive people use, to create opportunities to abuse, to get their ‘victims’ used to more intimate contact, and to make sure that the abuse is kept secret)?
• Is there a member of staff who is the only person who performs or is able to perform certain tasks with a particular person (for example, dealing with their distressed behaviour)?
• Do members of staff do things with people that are for their own benefit rather than the person’s benefit (for example, taking the people out so the members of staff can do their own shopping)?
• Do members of staff spend time at work on their days off?
• Is there a risk that tangled family boundaries exist where families and/or couples work in the same service? Is this well-managed?
• Do the families, including children, of members of staff come in and get involved in what goes on in the service, inappropriately?
• Do members of staff keep an open mind when others are accused of abuse?
• Do managers and staff follow procedural requirements in offering support to members of staff when concerns have been raised?
• Do members of staff tell different stories to explain something that has, or has not, happened?
• Is suspected or actual abuse reported through official channels?
• Is there a denial or lack of concern where the possibility of abuse is raised? 
• Do members of staff accept that abuse could be carried out by other members of staff?
• Are serious situations accepted and not questioned, and is their significance appreciated?
• Is there a reluctance to acknowledge abusive behaviours and to intervene? 
• Do members of staff turn a ‘blind eye’ or fail to act when people are abusing, hurting or controlling others (that is, do they fail to recognise behaviours or language as abusive)?
• Are connections made between the onset of behaviour change and other significant events (for example, the beginning or end of a relationship)? 
• Do members of staff know what to do when they suspect or have evidence of abuse?

• Is there support for staff if they’ve had to deal with a difficult situation?  Do they get the chance to de-brief or talk it through with a supervisor or manager? Is possible trauma for staff recognised?
• Are members of staff and managers reluctant to ask for support from external practitioners or to work alongside them?
• Do staff demonstrate hostile attitudes to visitors including relatives, treating them as unwelcome or as intrusive?
• Are there concerns about the staff or managers resisting the involvement of external people, including external agencies or professionals?  Do staff or management respond negatively or defensively to suggestions, questions and criticisms?
• Are members of staff critical or undermining of external professionals? 
• Is there is a lack of monitoring by outside agencies?
• Do the staff or managers deny problems?  Do they appear to be in denial about difficulties that are being experienced?
• Do staff have defensive or aggressive attitudes? Are members of staff persistently not being open about things that happen? Do they make excuses? Do members of staff say things which appear to be untrue or unfounded?
• Are there concerns about the staff isolating individuals unnecessarily or without a risk assessment or care and support plan that supports this (for example, by asking a person to stay in their room on their own, or by walking away and leaving a person on their own)? 
• Are there failings on the part of the management to submit mandatory information such as notifications or safeguarding referrals? Does someone from the service respond to CQC, commissioners or other external requests for information in a timely way?  Is there poor liaison with external people?
• Are meetings, appointments or training events frequently cancelled without good reason?
• Are important meetings arranged at very short notice, making it difficult for external people to attend?
• How are people who lack the mental capacity in relation to their care and support, supported to make day-to- day decisions? Are staff familiar with the Mental Capacity Act and do they know how to assess capacity and how to make best interests decisions?
• Where people’s mental capacity is an issue, and a deprivation of liberty authorisation is in place, how are arrangements reviewed? 
• Is access to the general practitioner (GP) and other health services well-supported, when required? This could include annual learning disability health checks, management of long-term conditions with district nursing services, opticians, dentists, as well as hospital and other clinic appointments.
• Has the number of people placed a long way from home increased since the contract was let?
• Do people appear to be cut off from other people or to have little contact with outside world?
• Are people provided with privacy and/or external advocacy to help them communicate? 
• Who maintains contact? How is contact maintained with the outside world?  
• If a person has family or friends, are they in regular contact, and supported to feed back any concerns that arise? 
• Are people supported to maintain contact (for example using video conferencing) with family and professionals? If so, how?  If not, do you have concerns that there is a lack of initiatives to support regular outside contact and that people have little involvement, contact or relationships with people who are not paid staff?
• Are you concerned that systems for communication with outside agencies are weak?
• Do staff help people (including self-funders) to get independent representation or support (for example independent advocacy)?
• Have you asked the people who draw on services all the relevant questions that you could ask?
• Have you asked the families or friends of people who draw on services all the relevant questions that you could ask?
• Have you asked the provider managers and staff all the relevant questions that you could ask?
• Have you asked the professionals and other practitioners all the relevant questions that you could ask?
• Have you triangulated all the information gathered, including observations and data from complaints, intelligence shared by CQC, safeguarding colleagues and other commissioners?

Once the provider has been selected and a service is running, people will visit to check that it is going ok. Here are some questions that can be used to check the views of people who draw on the service:

• How do you feel about where you live? What do you like about it? What could be better?
• Do you think that staff behave differently from usual when people from outside are expected to visit?
• Are you able to see family or friends if you want to?
• Are you supported to go to appointments, like the doctor, the hospital, the hairdresser?
• Do you feel okay to raise concerns if you have any?
• Are some people able to speak up about concerns, but don’t, because they are afraid to do so? Might they be worried they would get into trouble if they did?
• Might anyone think that even if they spoke up, nobody would listen to them or really hear what they are saying? Is this a real problem?
• Are you able to have contact with family and friends when you want to? If they can’t visit, can you contact them by phone or video call?
• Is there anything that you want to do that you are not allowed to do?
• Is there anything that you would like to tell me about that makes you happy or pleased?
• Do you feel like you are treated with respect?  Is it accepted that everyone is different, and each person likes or dislikes different things?
• Is there anything that you would like to tell me about that makes you unhappy?
• Do you ever feel punished, threatened or ignored?  Is it ever for long periods of time?
• Do you feel that any staff are impatient or intolerant of anyone who lives here?
• Do any staff raise their voice or shout at people?
• Is there a particular group of staff who seem to be in charge of the way things happen in the service, even though they may not be the manager?
• Do you have any personal possessions? If not, why is that? What do you have and where is it kept? Can you access your things easily without having to get permission? Who decides?  Are there clear rules? Do things get decided by staff?
• Do you feel different with different members of staff?
• Do you think the staff change their behaviour when external people are expected to visit?
• Do you feel happier or more relaxed in different places?

When a person has family and friends, they will often be the first to highlight concerns and can often maintain more regular contact with a loved one than professionals.

• How is your loved one? Are there any noticeable changes in their presentation or their appearance?
• Are you aware of how your loved one is being cared for?
• Is he or she behaving in ways which suggest that their support is ineffective or inappropriate?
• Do you know how to raise concerns if you are worried? 
• Do you know what to look out for? 
• Does it feel like a “closed” or an “open” sort of place? 
• Do you and your family have a good working relationship with the provider?
• Do members of staff support people to maintain links with family and friends, advocates and other practitioners (for example, do they pass on messages, do they return phone calls, do they ensure advice and information is shared among all the team)?
• Do members of staff regularly forget or appear not to know when family, friends or professionals are due to visit?
• When you visit, does the person you visit wear shoes or slippers? Is that their choice? Do they fit/look okay?
• Does your loved one ever appear scared? Do they talk about not feeling safe?
• Do they talk of any people who control, bully or harm others? 
• Do they understand what abuse is? Do they understand that they should not be abused and also that certain actions may expose them to the risk of abuse (depending on context, this may include online abuse, sexual exploitation, trafficking, drugs, running away)?
• Are you concerned that there may be people who might be abusing others and who may not understand or respect the idea of consent?
• Is the person generally comfortable and supported to keep clean and tidy? 
• When you visit, do you have any concerns about what you see, hear or smell? This could include concerns about cleanliness, damp, support with personal hygiene and oral health. 
• What parts of their life do they have choice and control over? What support are they offered with this? What decisions can they make for themself? 
• Where are the staff when you visit? Are they visible? What are they doing if they are not interacting with someone? 
• Does the person have their own possessions? If not, why not? 
• How do new staff find out what they need to know about each person quickly? Do staff know the person above and beyond their name and diagnosis? How do staff know these things? How is information reviewed and updated? 
• Do the staff know who is important to the person, and do they know why?  
• Are the things that are important to people maintained, for example, hair styled the way they want it, shaved, or not shaved, wearing perfume? 
• Do staff appear to know the name of the person’s partner, mother, father, best friend?  And do staff know, for example, what the person’s favourite television programme or favourite band is, whether they have a pet? Do they like reading? If so, what do they like to read? 
• Do staff maintain professional boundaries? Do they flirt with people inappropriately?
• Have staff checked what the person likes to be called? Have they given people nicknames that might be hurtful? 
• Where do staff sit? Is there a separate staff room? Is there a separate staff toilet?
• Was information about rights provided to you when you family member first arrived, and is this kept up-to-date as required and re-sent regularly?
• Have the behaviours of your loved one changed?
• Is the person expressing emotional changes by their behaviours – for example, have they become withdrawn, weepy or anxious?
• Has the person’s communication changed – for example, has the person started to communicate differently or stopped communicating?
• Have the person’s needs changed – for example, do they need or ask for different types of care or support, or different levels of care and support?
• Have the person’s skills changed – for example, have their self-care or continence management skills changed, with no explanation about why?
• Does the person behave differently with different members of staff?
• Do you think the staff change their behaviour when external people are expected to visit?
• Does the person seem much happier or more relaxed in different environments? 
• Does the person engage in self-harm?
• Does the person engage in inappropriate sexualised behaviours?
• Does the person have any physical injuries?
• Where relevant, do measures introduced to protect the person make a difference?
• Does your loved one ever talk about boyfriends or girlfriends or the possibility of pregnancy or babies, when they may need support to understand positive relationships, sexual relationships and the risks associated with this, including safe sex, pregnancy and childbirth?
• Would you be worried about making a complaint? If yes, what would you worry about?

• Are staff supported and encouraged to 'speak out' and raise concerns or are staff actively discouraged?  Are staff afraid to do so (this may be due to ineffective whistleblowing policies, or a lack of support and guidance for staff)?
• How do new staff get to know the people they support and find out what they need to know about each person quickly? Is there a one-page profile for each person?
• Which visiting professionals review care plans and daily notes?
• Do you have both computerised records and hard copy files?  And if so, which do you offer to external professionals for review? 
• If you use computerised records, is there anything that you don’t scan on to the computerised care plans and daily notes?
• Are there other records that you keep that are separate from the care plans and daily notes?  If so, what do you keep separate, and why (could include vaccination records, Deprivation of Liberty Safeguards (DoLS) paperwork, “Do not attempt cardiopulmonary resuscitation” (DNACPR) forms)?
• Can people you support write in the care notes, if able? Do you let them see and read their care and support notes? Are the notes written respectfully?  
• Where do you record visits from family or friends? 
• Where do you record visits from external health and social care colleagues and independent advocates?
• Do you invite health and social care colleagues (and other regular visitors, for example, advocates, chaplains) to write about their visits in the care and support plans for each person?
• Do you discourage visits at mealtimes? Why is this?
• Do you have 'open door' practices – managers being open to staff/family/ friends who want to raise a question or concern?
• Do members of staff believe they have received enough training? 
• Is information about rights routinely provided to people and their families when they first arrive, and is this repeated regularly?

• How are the people who live at the setting or use the support or service?
• Are they behaving in ways which suggest that their support is ineffective or inappropriate?
• Are there any noticeable changes in their presentation or their appearance?
• Are you in a position to keep an ear/eye out for people other than the person you are visiting, who may not have any family or friends that visit, and raise concerns, if appropriate?  Have you noticed anything about anyone else?
• Does the person you are visiting know why you are there?
• Is the person involved in meetings about the assessment or review of their care and support needs and the support to be provided? If not, why not? Are care and support plans co-produced with the person and their family, advocate or other representative? If the person is not able to participate, even with support, are care and support plans individualised and do they reflect the person's voice?
• Does the care and support that is delivered reflect the care and support plans? Are people receiving the level of care and support that has been agreed, including any additional hours?
• Can people who live at the setting write in the care notes, if able? Are they given the opportunity to read them, if able? Are the notes written about them respectful?
• How well does the provider communicate and collaborate with external organisations such as your own?
• Were you able to see people on their own and discuss things confidentially?
• Who opened the door to let you in? How were you greeted?
• When concerns arise, do you feel like the staff may feign compliance, pretending that they agree and then doing nothing about it afterwards?
• Do you have any gut feelings that make you feel concerned? Does everything look 'too perfect?'
• Do members of staff appear to value people with a learning disability and autistic people, or treat them as somehow “different” from themselves and other people?
• Do members of staff use judgemental language when talking about, or to, people, or give a negative impression when talking about them?
• Do managers role model positive values and language?
• Are plans made for people on the basis of what is practical for the organisation or staff, rather than the individual person’s needs and wishes?
• Do members of staff appear to feel powerless or reluctant to make decisions, or do they appear afraid of making errors?
• Do staff or managers insist on being present at meetings between people and practitioners – even when there is no need for them to be there, and the person has a right to a private meeting?
• Do members of staff regularly forget or appear not to know when family, friends or professionals are due to visit?
• Are tasks requested by professionals forgotten or incorrectly carried out?
• Do people often attend appointments with professionals at the wrong time/without appropriate paperwork/accompanied by different staff members who don’t know about previous activity?
• Are there discrepancies between the amount of money people are expected to have and the amount they actually have or in the value of items bought with their money?
• Do members of staff disagree with managers, resulting in them not following managers’ recommendations and guidance?
• Do different members of staff respond differently in response to a person’s behaviours?
• Do you have concerns about poor communication within the staff team?
• Do members of staff think about or take into account the person’s individual needs?
• Do members of staff appear to pay lip-service to the view that a person has choices, without thinking through whether the person is able to understand risks and consequences?
• Do members of staff understand how people communicate their consent or say 'no?'
• Do members of staff understand about consent in relationships, where relevant? Do they appear to have a good basis for judging whether two people are consenting to be in a relationship?
• Do members of staff describe people as boyfriend and girlfriend when it appears that one of them probably does not consent to the relationship?
• When you visit, does the person you visit wear shoes or slippers? Is that their choice? Do they fit/look okay?
• Does the person appear scared?
• When you visit, do you have any concerns about what you see, hear or smell? This could include concerns about cleanliness, damp, support with personal hygiene and oral health.
• Did the person choose what they are wearing?
• What parts of their life does the person have choice and control over? What support are they offered with this? What decisions can the person make?
• Where are the staff when you visit? Are they visible? What are they doing if they are not interacting with someone?
• Does the person have their own possessions? If not, why not? Are they supported to look after their own money or mobile phone?
• How do new staff find out what they need to know about someone quickly? For example, is there a one-page profile for each person?
• Do staff know the person above and beyond their name and diagnosis? How do staff know these things? How is information reviewed and updated?
• Do the staff know who is important to the person, and do they know why?
• Are the things that are important to people maintained, for example, hair styled the way they want it, shaved, or not shaved, wearing perfume?
• Do staff appear to know the name of the person’s partner, mother, father, best friend? And do staff know, for example, what the person’s favourite television programme or favourite band is, whether they have a pet? Do they like reading? If so, what do they like to read?
• Do staff maintain professional boundaries? Do they flirt with people inappropriately?
• Have staff checked what the person likes to be called. Have they given people nicknames that might be hurtful?
• Where do staff sit? Is there a separate staff room? Is there a separate staff toilet?
• Are people’s files/work documentation left out on kitchen/living room tables?
• Do staff understand and speak warmly about the people they are caring for?
• Is there a lack of reasonable adjustments for disabled people?
• Are there good communication plans for people who have communication needs?
• Are communication plans followed by staff?
• Is there a view that the service may be unsuitable for one or more people, but that no better option is available?  If so, how is that being managed?
• Do members of staff or others consider that this is the only place that the person could live? Do you share this view?
• Is there pressure to make the service work because of a perceived or actual lack of alternative provision?
• Have the behaviours of the person you visit changed?
• Is the person expressing emotional changes by their behaviours – for example, have they become withdrawn, weepy or anxious?
• Has the person’s communication changed – for example, has the person started to communicate differently or stopped communicating?
• Have the person’s needs changed – for example, the person needs or asks for different types of care, or different levels of care?
• Have the person’s skills changed – for example, have their self-care or continence management skills changed?
• Does the person behave very differently with different members of staff?
• Do you think the staff change their behaviour when external people are expected to visit?
• Do the person seem much happier or more relaxed in different environments?
• Does the person engage in self-harm?
• Does the person engage in inappropriate sexualised behaviours?
• Does the person have a number of physical injuries?
• Where relevant, do measures which were introduced to protect the person make a difference?
• Does the person show signs of fear, or talk about not feeling safe?
• Do they talk of people who control, bully or harm others?
• Are there people who might be abusing others, and may not understand or respect the idea of consent?
• Are there any people who talk about boyfriends/girlfriends or the possibility of pregnancy or babies, when they may need support to understand positive relationships, sexual relationships and the risks associated with this, including safe sex,  pregnancy and childbirth?
• Does the person understand what abuse is? Do they understand that they should not be abused and also that certain actions may expose them to the risk of abuse (this may include online abuse, sexual exploitation, trafficking, drugs, running away)?.

• Are any improvement requirements clear?
• Is there a jointly agreed action plan to address the required improvements? 
  If organisations are local, can their staff access training for staff via your organisation? Is that offer being taken up?
• Are there other training options available? 
• Are expectations about training (such as that provided by the Skills for Care online) included as a requirement in commissioning processes?
• Can you help with advice about recruitment and induction? 
• Do managers need to help to establish complaints procedures, or ideas about how to deal positively with concerns, so that they generate change, as well as an early indication of concerns?  

If concerns are raised when people visit, and it is decided that something needs to be changed and improved. These are some questions that may be used to check about improvements.  

• Do you know about the changes that have been asked for?
• Are you concerned that some staff may pretend that they agree with required changes and then not do anything about it afterwards?
• How will you know when it is better?
• How can we ensure you can feedback to us on improvement or otherwise during this period?
• Do you think things have improved?

• If it is decided that things need to improve, how will you recognise/identify improvement?
• How can we ensure you can feedback to us on improvement or otherwise during this period? 
• Do you have any concerns that people who work at the setting may feign compliance, pretending that they agree with required changes and then not following through with their actions? 

• Are you clear what your required improvement actions are? For example, is there an action plan with actions attributed to specific people or job roles, with required completion dates and clarity on dependencies, if relevant?
• Are you clear how improvement will be measured by commissioners and CQC?

• If improvement is required, how will you recognise/identify improvement?
  How can we ensure you can feedback to us on improvement or otherwise during this period? 
• Do you have any concerns that people who work at the setting may still feign compliance, pretending that they agree with required changes but perhaps not following through with their actions?