Closed cultures in social care: Guidance and questions to ask

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'Closed cultures' have been identified as a major risk to the wellbeing and human rights of people with care and support needs, who are unable to protect themselves from abuse or neglect, due to their care and support needs. The aim of this document is to provide guidance for the council workforce on identifying where a ‘closed culture’ may exist, or there may be a risk of one developing, in social care services for people with a learning disability and autistic people.

Executive summary

Closed cultures have been identified in many national safeguarding reports as one of the biggest risk factors facing people with a learning disability and autistic people receiving social care services.

In response to this, the Care Quality Commission has undertaken work to train their inspectors to recognise and respond to closed cultures in registered health and social care services.

Council commissioners of social care services for people with a learning disability and autistic people also have a role in identifying where a ‘closed culture’ may exist, or where there may be a risk of one developing, in social care services. This includes services for autistic people who do not have a learning disability as well as autistic people who do have a learning disability.

This resource is aimed at supporting commissioners with this task and has been informed by council adult social care commissioners and practitioners who commission services for people with a learning disability and autistic people or work with people with a learning disability and autistic people.

This resource is aimed at council commissioners of social care services for people with a learning disability and autistic people, to ensure they understand what a closed culture is and how such cultures can impact on the lives and safety of people who draw on services.  

It is aimed at supporting commissioners to recognise an emerging or existing closed culture, and to support and encourage providers to change a closed culture to a better culture.

The resource offers both guidance to inform commissioners and suggested sets of questions that commissioners can use at various stages of the commissioning cycle, to identify where there is an increased risk or evidence of a closed culture, in a social care service. 

The guidance aims to equip commissioners and contract compliance staff to recognise the warning signs that a closed culture may exist or be emerging in a social care service.  

It recognises that there are inherent risks associated with some services, and builds on the indicators of closed cultures identified by the Care Quality Commission (CQC), associated with:

  • poor care and support
  • management and leadership
  • skills, training and supervision of the staff providing support
  • external oversight.

It emphasises:

  • the importance of recognising when a poor culture may be developing
  • the importance of having visitors from outside a setting and listening to their feedback
  • additional risk where services are a long way from “home”, as there may be fewer visitors that know a person who cannot speak up for themselves
  • risks that can be associated with 'specialist' services that provide everything themselves, and therefore call on fewer (if any) external services.

Guidance is provided on what closed cultures are, and commissioners are encouraged to consider the risk of closed cultures at each stage of the social care commissioning process, and also throughout the period of a contract, when monitoring contracts with existing contracted providers to ensure that any risks of emerging closed cultures are recognised, so that action can be taken.

Guidance is provided on the role of commissioners and contract monitoring staff in relation to potential closed cultures. The resource highlights the importance of other visitors to services, and emphasises the importance of commissioners having good regular lines of communication with visiting practitioners from across social care, CQC and health.

It also emphasises the importance of talking to people who draw on services themselves as well as their friends and family. Intelligence from these different sources of information will enable contract monitoring staff to triangulate information and data from different sources, to inform their judgment on whether a closed culture may exist or whether there is a risk that one may be developing in a service.

The guidance also raises a range of matters for commissioners to consider in relation to closed cultures, that have been identified by commissioners from their experience, as important to think about in the context of closed cultures and the risk they pose.  The 'Things to consider' section offers learning from the sector in relation to closed cultures.

In addition to the guidance provided, the resource offers a number of question sets that can be used at different stages of the commissioning process.

Commissioners can find questions for use when visiting services, and also questions that may be useful to ask particular groups of people such as visiting practitioners, people who draw on the service and families and carers.  These are not prescriptive, but may help commissioning staff to frame conversations, which in turn may inform their judgments about the risk of closed cultures in those services.

Some questions may also prove useful in other contexts, such as during a safeguarding enquiry.  It does not focus on hospitals or other health services, as these are not commissioned by councils, although it is recognised that the NHS may commission services from some social care providers. It is also noted that much of the guidance may be of value to health or education commissioners of services for adults or children.

Although the guidance has been specifically developed in relation to services for people with a learning disability and autistic people, it may be relevant to services for other people, that is, who do not have a learning disability and who are not autistic.

Both the guidance and the question sets draw on published research and reports that have highlighted the serious risk posed by closed cultures in social care services.  They build on work done by the CQC in response to various national reports about safeguarding concerns in registered services.


This guidance draws on work by the Care Quality Commission (CQC) to improve their approach to recognising and responding to closed cultures and also takes account of learning from recent reviews of, and reports about, services where there has been organisational abuse. 

Closed cultures have been identified as a major risk to the wellbeing and human rights of people with care and support needs, who are unable to protect themselves from abuse or neglect, due to their care and support needs.

What is a closed culture?

In How CQC identifies and responds to closed cultures (May 2022), the CQC defines a closed culture as 'a poor culture that can lead to harm, including human rights breaches such as abuse'.

A closed culture is one where it is unlikely that many outsiders go in. Fewer external people are able to observe everyday practice in the setting. The only people who are present on an everyday basis are those who use the services or those who work for the service provider and are therefore likely to be part of the organisational culture of the provider (although whistleblowers may maintain a separation).

This document also explores other factors that may influence the risk of closed cultures developing. It is also possible for closed cultures to occur in services even where people do visit – this can be seen in terms of sub-cultures. Whilst institutionalised practices can be challenged if and when seen, if such practices are not observed they may go unchallenged.

It should be noted that a person’s human rights and dignity can be abused in settings where there is not a closed culture, and abuse is therefore not only a risk where there is a closed culture. But where there is a closed culture, concerns are less likely to be observed, reported or even considered, and therefore are more likely to go unchallenged and un-addressed.


We therefore need to make every effort to find out what a service is like, listening to everyone who visits, to identify closed cultures and minimise the risk of harm.

The Safeguarding children with disabilities and complex health needs in residential settings Phase 1 report (October 2022) recognised (para 10.3) that:

While no system, however robust, can fully eliminate all risk of harm and abuse, those risks were exacerbated by wider systemic failings arising from inadequate leadership and management, poor quality training, support and supervision of the workforce,weak compliance with legal requirements and regulatory failure.”

The Phase 2 report (April 2023), which focused on wider systemic issues, identified (Appendix D) the “detrimental impact of ‘closed culture’ in residential settings,”, as the “lack of openness to external scrutiny and challenge; limited involvement from other agencies; limited learning and review from practice to inform improvement; risk of abuse where children are highly dependent on adult care givers.”

Although these two reports were about children’s services, these statements and much of the learning apply equally in adult services.

Council commissioners and practitioners have a crucial role in looking out for closed cultures and recognising when there may be a closed culture in a service or there may be a risk of such a culture developing.

The CQC talks of “indicators” that a closed culture may exist, and then, for each, describes “inherent risks” that leads the CQC to monitor the service closely, and “warning signs” that CQC inspectors look out for.

This built on earlier guidance for inspectors.  The four indicators are:

  • people may experience poor care, including unlawful restrictions
  • weak leadership and management
  • poor skills, training and supervision of staff providing.
  • lack of external oversight.

The Safeguarding children with disabilities and complex health needs in residential settings Phase 2 report (April 2023) added an additional key risk factor: Staff not encouraged to raise safeguarding or wider practice concerns and not supported if they do so.

The presence of one or more inherent risk factors is not proof that there is an abusive, punitive or closed culture, but could be a sign that there is an increased chance of one developing, or that if one does develop, it may not be observed or recognised.

Lack of external oversight can be a major issue when people who draw on a service are living a long way from their home area, and family members and practitioners from that area, who may otherwise be able to visit more often, cannot do so.

The involvement of, and communication with, independent advocates can be crucial in such situations. Lack of external oversight can also be an issue where everything is provided by the provider, such as leisure activities or haircuts

Some large companies employ their own staff in therapeutic services, or as advocates, so there are then fewer independent visiting professionals. More autonomy for providers can lead to higher risk, if the required checks and balances do not exist.

The importance of visitors cannot be emphasised too highly.  The Department of Health and Social Care has indicated that it wants to ensure that visiting is protected and that it remains a priority for health and care providers so that patients and residents can receive visitors in care homes, hospices and hospitals, whenever it is reasonable and safe. In 2023 the government undertook a public consultation about this, to inform how to enshrine the right to visiting in law.

Some closed cultures have been found to actively discourage outsiders from visiting. Others may not appear to discourage visitors, but are simply a long way away, or very difficult to get to.

It is essential to consider the culture of a provider as part of commissioning decisions, especially when making a decision that a person should move to a service that is a great distance from home, or in a rural area with little or no public transport.

It is also essential to explore the readiness of a provider to accept people from long distances, and how they ensure contact with family, friends and familiar practitioners, to reduce the risk of closed cultures.

Where it is proposed that a service is required from a “specialist” provider, there may not be many alternatives available, and places may be in demand.

Some provide a holistic service with all 'wrap-around' services included, reducing the need for visiting professionals, and in this context, it is essential to consider the importance of external oversight.  Some may claim an unparalleled level of expertise, which should be tested and evidenced.

CQC suggests that certain 'features' of services will increase the potential for the inherent risks to be present (and in turn this will increase the risk of a closed culture developing):

  • services where people are unable to leave of their own accord
  • live-in services such as shared lives, supported living services
  • any service where one-to-one care is provided (so there may be no other witnesses to poor practice)
  • provider changing the type of service it offers in response to market or other influences.

Commissioners should therefore be mindful of such features in services they commission.

What is the role of social care commissioners in relation to closed cultures?

Wider responsibilities of commissioners include strategic commissioning and market-shaping, facilitating and shaping diverse and sustainable markets to enable high quality care and support which benefits the local population. This includes exploring the needs of the local communities, including autistic people and people with a learning disability, and agreeing the future needs of the local population.

When subsequently commissioning services to meet need, commissioners have a role in ensuring their council does not commission from providers where closed cultures already exist, by asking relevant questions before procuring and contracting for services.

They then have a role throughout the commissioning and contract compliance cycle, visiting services, reviewing paperwork, using observation and asking pertinent questions when visiting, as well as noting feedback from various stakeholders. Feedback may be received from:

  • people who draw on the services
  • their families, friends and independent advocates (particularly where a person does not have any family or friends who visit), as well as from
  • professionals, clinicians and practitioners
  • other commissioners, regulators and inspectors.

It is essential that where concerns are raised, they are taken seriously.  Commissioners should triangulate available data and information, that is, comparing information from different sources, to check whether they match.

Information and feedback, to be triangulated by social care commissioners, may be received following needs assessments, care and support reviews, health reviews, complaints and compliments, safeguarding concerns and enquiries and visits by other commissioners (from health or children’s services) and inspectors from CQC or Ofsted.

It is essential that social care commissioners develop avenues for communication to ensure that there are no barriers to feedback from people who are able to observe issues and spot warning signs that a closed culture may be developing will enable this risk to be explored.

They should explore with health commissioners how to ensure that staff in primary and community healthcare services are trained in what to look out for, and that there are clear routes for information to be received from these sources and how different sources of information can best be brought together.  This may include the following sources:

  • long-term condition management involving the district nursing service
  • annual health checks for people with a learning disability (for some, there may also be dementia reviews)
  • flu and covid vaccination sessions in social care settings
  • regular GP visits to social care settings
  • medicine reviews involving pharmacies

Many local areas have well-developed, regular meetings between health and social care commissioners to share up-to-date intelligence on quality issues that have been identified in specific social care services or settings, with input from safeguarding leads, where relevant.

Some arrangements involve CQC representatives (both regulation and inspection representatives). Some focus on adults or children’s services (including residential education settings), some cover both. These meetings enable an understanding of any improvement actions required from each organisation and a coordinated approach to scheduling visits, with frequency of such meetings ranging from fortnightly to quarterly.

Some have established RAG rating systems for registered services in the area, to identify providers that require the most improvement and to enable a focus on providers or settings of concern. It is good practice to keep the methods and impact of such approaches under review, considering whether any changes can make them more effective.

Once the risk of a closed culture is recognised, this issue can be raised with providers. By exploring the risk of a closed culture developing, commissioners may be able to work with the provider and other practitioners, to prevent or reduce the likelihood of it happening, and this in turn, may reduce the risk of harm to people who draw on the service.

Commissioning a service at a strategic level, is likely to involve the following stages:

  1. Developing the specification
  2. Inviting tenders 
  3. Evaluating tenders
  4. Letting the contract
  5. Routine contract compliance visits
  6. Taking any required follow-up action, working with the person, their families/carers, advocates, CQC, the provider and practitioners. 

At each of these stages, commissioners should be considering the risks associated with closed cultures, whether there is a risk of a closed culture developing and, if so, what action may be required. This guidance lists some questions that can be used at the different stages of the commissioning process to help an enquiring mind consider the issues.

What is the role of other practitioners in relation to closed cultures?

Social care practitioners have the following responsibilities:

  • Assessing needs and developing care and support plans 
  • Working with, and listening to, the person, their family and colleagues to inform commissioners and local brokerage services of requirements
  • Exploring available options to meet needs.  This involves promoting independence, choice and control and opportunities for citizenship and engagement in the wider community, as appropriate 
  • Exploring the need for authorisation of a deprivation of liberty, from either the council supervisory body or the Court of Protection 
  • Setting up accommodation and care and support 
  • Regular review of needs and arrangements to meet the eligible needs of individuals
  • Responding to concerns (complaints, safeguarding, other) and ensuring that these feed into people responsible for contract compliance 

When engaging in any way with the person, their family, the provider or others, practitioners should be alert to the risks of a closed culture, and if they suspect the workplace culture in the service is at risk of becoming closed, they should raise this concern with commissioners, drawing their attention to this risk. Any safeguarding concerns should be raised, as appropriate.

Things to consider

Questions to ask

The stages of commissioning cycle are used in this part of the guidance to order and structure the questions suggested.

The following commissioning cycle stages are used:

  • Developing the specification
  • Inviting tenders
  • Evaluating tenders
  • Letting the contract
  • Visiting providers, to undertake routine contract compliance checks or to visit individuals for a variety of reasons, including to undertake reviews of a person’s needs or their support plan
  • Taking any required follow-up action, working with the person, their families/carers, CQC, the provider and practitioners

There may be different audiences or individuals that questions would be addressed to, from whom commissioners can draw together answers, including:

  • commissioners
  • people who are supported by a service
  • families, friends or representatives of people supported by a service
  • providers
  • other practitioners and professionals who visit.

Questions in this part of the guidance have been put together and adapted from various sources:

  • How CQC identifies and responds to closed cultures - Care Quality Commission (May 2022)
  • “Early Indicators of Concern in Residential Support Services for People with Learning Disabilities” (October 2012, Dave Marsland, Peter Oakes and Caroline White, University of Hull, Centre for Applied Research and Evaluation) The Abuse in Care? Project.
  • ADASS “Safeguarding people in ‘closed’ environments” checklist (2020)
  • Local work shared by various reference group members

Developing the specification

When you are developing the specification for a service, it will be important to draw on the views of people who will draw on the service, their family, health and social care practitioners and potential providers.

Inviting tenders

When designing the tender process, it will be important to think about how you will involve people with a learning disability and autistic people in the evaluation process and how you will make sure the materials and process will be accessible to, and informed by, them, as well as their families and representatives. This will enable people with lived experience to contribute to the evaluation of tenders.

Evaluating tenders

Those evaluating the tender may include people who may draw on the service or support, family members, friends or representatives of people who draw on the service and other social care or health practitioners and professionals.   This means that information will need to be presented in a way that can enable everyone, including experts by experience and their carers, to form a view about the tender response.

For each provider being evaluated, it will be important to judge the provider’s 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.

It will be essential to make a judgement about the inherent risks that CQC identify, as CQC suggests that the presence of one of these could be a sign that there is an increased chance of a closed culture developing. The following questions will help those evaluating tenders to recognise if the inherent risks identified by CQC are present.  Commissioners should satisfy themselves that the provider understands these risks and how to take action to ensure a closed culture does not develop.

It is essential to note that the absence of the inherent risk factors described is not a guarantee that a closed culture will not develop and it is essential to note that closed cultures can also emerge in services without those risk factors.

Commissioners should consider a wide range of factors.  The following questions should help with this.

Letting the contract

This point in the commissioning cycle will be when providers and commissioners need to be absolutely clear how the contract will operate.  It will be essential that references to closed cultures and the risk they present are unambiguous for all concerned.

Visiting settings

However clear the agreements are at the beginning of a contract period, there is always a risk of cultures shifting as some staff leave, new staff start and staff groups evolve. The following questions are listed under the four main CQC indicators, and although intended for contract compliance staff, can be used by anyone undertaking visits throughout the delivery of the support or service. 

Taking any required follow-up action

It will generally be commissioners or CQC that require follow-up improvement actions if they suspect a closed culture exists or is at risk of emerging.  In judging whether improvement has been achieved, they may seek views from the person or people who draw on the support or service, their families and other representatives, staff working in the service, and practitioners who visit. 

This will be particularly important for people who have raised concerns about culture, quality or safeguarding issues, including human rights concerns and equalities concerns.