DUTY OF CANDOR POLICY – Hierarchy Support Services

POLICY AND PROCEDURE: INTRODUCTION, RESPONSIBILITIES PROCESS
Owner& Designation Pamela Wallah, Director
Owner Signature P.Wallah
Authorized by Pamela Wallah
Designation Director
Authorization Date & June 2020 P.Wallah

Revisions Date Revision
Version 1 June 2020 Policy Introduced
Version 2 June 2021 Policy Updated
Version 3 June 2022 Policy Reviewed
Version 4 June 2023Policy Reviewed

Policy Statement
Related regulation: Health (Tobacco, Nicotine etc. and Care) (Scotland) Act 2016

We have a duty to acknowledge when something has gone wrong and provide an
honest explanation. Being open, honest, and transparent is the key to developing
good relations, trust, and partnership between people and those who care for
them.
Hierarchy Business Solutions Limited has clear expectations for leadership
behaviors and attitudes to support openness and learning. All behaviors and
attitudes should encourage cultural change and ensure the infrastructure is in place
to support this.
Staff will feel confident that they will be safe and supported to report duty of candour
incidents so that lessons are learned and shared to improve and increase the safety
of our care system for everyone.
- Recording and Reporting
  All duty of candour incidents will be monitored, recorded, and reported by staff within
  Hierarchy Business Solutions Limited. Hierarchy Business Solutions Limited will produce an
  annual report which will outline:
The number and nature of unintended or unexpected incidents which have resulted
in death or harm.
Assessment of the extent to which the duty was conducted.
Information about the organisation’s policies and procedures to support
implementation of the duty of candour provisions.
Any changes made to policies or practice as a result of the incidents reported.
- What is harm?
  Severe harm is:
When someone dies
The permanent disability either physical or psychological (such as removal of the
wrong limb or organ, or brain damage
- Not severe harm:
An increase in treatment
Changes to the structure of their body
Shortening of their life
An impairment which can be sensory, motor, or intellectual and has lasted or is
likely to last at least 28 days.
Pain or psychological harm which lasts, or is likely to last, for at least 28 days.
Harm also includes the person requiring treatment by a health professional to
prevent:
Their Death
An injury to them which, if left untreated, would lead to one or more of the harms
outlined.
When is the duty of Condor triggered?
The procedure should be triggered as soon as a regulated health professional
confirms that an unintended or unexpected incident has occurred and has resulted in
harm or death, as laid out in the policy. This health professional must NOT be
involved in the incident.
The duty of candour procedure can also be triggered as a result of a complaint or
feedback received, a significant event which triggers a review or a disclosure under
the whistleblowing policy.
If the Duty of Condor procedure is not triggered a clear audit trail must be kept of that
decision-making process.
All incidents should be reported and reviewed. You need to:
➢ Be able to recognise harm and whether this is unintended or unexpected.
➢ Understand what has gone wrong.
➢ Know who to speak with to discuss concerns/issues.
➢ Understand local decision-making processes and procedures to follow.
5 Key steps
The key steps in the duty of condor procedure should include:
Notifying the person and/or their family/carer that an unintended or unexpected
incident has occurred that has resulted in harm and the duty of candour procedure
will be activated.
Making an apology at this stage for what has happened.
Reporting through local systems and following local procedures which will involve
conducting a review of the incident and ensuring that the person and/or their family
are included in a way that meets their needs (ensuring that the review is undertaken
by an individual NOT involved in the incident)
Arranging to meet with the person concerned and/or their family to explain what has
gone wrong and actions that will be taken.
Providing a written account to the person and/or their family should the person wish
this.
(whilst the person may not want a written account, this should always be offered)
Asking how the person wants the information to be provided to them and advising
them how you are going to store their information.
Outlining support available for those affected including the person and/or their family
as well as staff involved.
Recording, reporting, and monitoring of the incident to ensure lessons are
learned and shared.
Saying Sorry
Sometime health and social care staff find it difficult to say sorry when something has gone
wrong harm has occurred. It can be difficult to know if we can say sorry for something that
has gone wrong and worry that the timings for doing this will not be right or that we will make
things worse.
Using the 4 R’s can help to get this right:
Reflect – stop and think about the situation.
Regret – give a sincere and meaningful apology.
Reason – If you know, explain why something has happened or not happened. If you
do not know, say that you will find out.
Remedy – Explain what actions you are going to take to ensure this will not
happen again, and what the organization learns from the incident.
An apology is a statement of regret in respect of the incident, it does not in itself amount to
an admission of negligence or a breach of statutory duty. It should be as soon as possible
after the event and should be sincere.
Communication
A lead person (Registered Manager) should be nominated to deal with internal
communication, external communication, and responsive communication.
Annual Reporting Requirements
Hierarchy Business Solutions Limited are required to report on an annual basis the following
things:
Number and nature of incidents.
How the duty was conducted
Policies and procedures for reporting and identifying incidents.
Any changes to police, procedure, or practice as a result of the incident i.e. learning
identified and shared, improvements made.
Support that was made available to individuals and staff to enable learning across
the organization appropriate information needs to be gathered through the review
process. This needs to be an ongoing process and not left to the end of the
procedure.
Related policies:
Hierarchy Business Solutions Limited Incident reporting policy and procedure
Hierarchy Business Solutions Limited Whistleblowing policy and procedure
Hierarchy Business Solutions Limited Complaints policy and procedure
Hierarchy Business Solutions Limited T/A Hierarchy Support Services. Registered No.SC596209
Training
Staff training covers the service ethos of openness and transparency, individual
responsibilities to act in open and transparent ways and the procedures the service will
follow in exercising its duty of condor following incidents that fall within its scope.
Alteration of this policy
This policy will be subject to review, revision, change updating, alteration, and replacement
in order to introduce new policies from time to time to reflect the changing needs of the
business and to comply with legislation. Any alterations will be communicated to you by the
Registered Manager.