Duty of Candour

Can staff articulate what it means to be open and transparent, and do they know how to report incidents that may trigger the Duty of Candour?

What we look for: Sample 3-5 staff members. They should understand they must immediately report errors or harm to the manager so families can be informed. Fails if staff believe they should hide mistakes or do not know the whistleblowing/incident process.

Evidence: Staff training matrix, records of staff interviews/supervisions, team meeting minutes

Is learning from incidents that trigger the Duty of Candour shared with the wider staff team to prevent recurrence?

What we look for: Check how the outcome of a DoC investigation was utilized. Staff should have been briefed (anonymously if needed) on what went wrong and what new practices to adopt. Fails if there is no evidence of shared learning following a major incident.

Evidence: Team meeting minutes, memos, newsletters, updated risk assessments, lessons learned logs

Is ongoing support offered to the relevant person (and the person using the service) in relation to the Notifiable Safety Incident?

What we look for: Look for evidence that the service checked in on the person's wellbeing after the incident, offering practical or emotional support (e.g., a follow-up meeting, adjusting care times). Fails if communication abruptly stopped after the legal letter was sent.

Evidence: Care plan updates, communication logs, referrals to advocacy or counseling, meeting minutes with families

Is there an up-to-date Duty of Candour policy that clearly defines Notifiable Safety Incidents (NSIs) in a domiciliary care context?

What we look for: Review the policy to ensure it explains the legal threshold for NSIs in community settings (e.g., severe harm, prolonged psychological harm, death). Fails if it only uses hospital/clinical examples or is past its review date.

Evidence: Duty of Candour Policy, Incident Management Policy, Staff Handbook

Are all accidents, incidents, and safeguarding alerts effectively triaged by management to identify if the Duty of Candour threshold is met?

What we look for: Select a sample of moderate-to-severe incidents from the last 3 months. Verify the manager has explicitly documented whether DoC was triggered. Fails if severe incidents occurred but DoC assessment was completely missed.

Evidence: Accident/Incident log, Safeguarding tracker, Manager triage notes or checklists

For identified NSIs, is there evidence that a verbal apology and explanation was provided to the relevant person as soon as reasonably practicable?

What we look for: Review the files of any recent NSIs. Look for clear documentation of a phone call or visit offering a sincere expression of sorrow or regret (an apology, not just an admission of liability). Fails if no verbal apology is documented.

Evidence: Client care notes, Incident reports, Duty of Candour log, Communication logs

Is the verbal notification followed by a formal written notification and apology detailing the incident and inquiries to be made?

What we look for: Check that a letter was sent following the verbal apology. It must contain a true account of the incident, what further inquiries will happen, and a written apology. Fails if the letter lacks a direct apology or is significantly delayed.

Evidence: Copies of DoC letters sent to clients/relatives, email correspondence, postal receipts

Does the service maintain a secure, comprehensive audit trail of all Duty of Candour correspondence and actions taken?

What we look for: Review the tracking system used for DoC. It should securely hold the incident details, dates of verbal/written apologies, and copies of letters. Fails if records are scattered, missing, or lack dates and signatures.

Evidence: Dedicated Duty of Candour register/log, central governance folder, archived correspondence