Care Clarity Support & Advocacy

Duty of Candour Policy

Duty of Candour Policy

Organisation: Care Clarity Support & Advocacy Ltd
Reference: CC-POL-CANDOUR-001
Issue date: 02 May 2026
Version: Status: Live policy

This Duty of Candour Policy has been reviewed with Section updated to explain governance roles. For these changes to reflect in the policy, the system details questionnaire will need to be updated. Underpinning knowledge references and Further Reading links have also been checked and updated.

  • The Care Act 2014
  • Equality Act 2010
  • The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
  • Health and Social Care Act 2008 (Registration and Regulated Activities) (Amendment)

Regulations 2015

  • Mental Capacity Act 2005
  • Mental Capacity Act Code of Practice
  • Data Protection Act 2018
  • The Health and Social Care Act 2008 (Regulated Activities) (Amendment) Regulations
  • UK GDPR
  • Health and Care Act 2022
  • criminal Justice and Courts Act 2015
  • Author: Action Against Medical Accidents, (2023), Duty of candour Available from: https://www.avma.org.uk/policy-campaigns/duty-of-candour/
  • Author: Department of Health and Social Care, (2014), Statutory duty of candour for health and adult social care providers Available from: https://www.gov.uk/ government/consultations/statutory-duty-of-candour-for-health-and-adult-social-care- providers
  • Author: CARE QUALITY COMMISSION (CQC), (2025), Notifiable safety incidents

Available from: https://www.cqc.org.uk/ notifiable-safety-incidents

  • Author: Nursing and Midwifery Council, (2022), Guidance on the professional duty of candour Available from: https://www.nmc.org.uk/ professional-duty-of-candour/
  • Author: Royal college of Nursing and General Medical Council, (2025), Duty of candour

Available from: https://www.rcn.org.uk/get-help/rcn-advice/duty-of-candour

  • Author: Care Quality Commission, (2025), Regulation 20: Duty of Candour (Provider

Guidance) Available from: https://www.cqc.org.uk/guidance-providers/regulations-enforcement/regulation-…

The company aims to

*Offer skilled care to enable people supported by us to achieve their optimum state of health and well-being. *Treat all people supported by us and all people who work here with respect at all times. *Uphold the human and citizenship rights of all who work and visit here and of all Clients. *Support individual choice and personal decision-making as the right of all Clients. *Respect and encourage the right of independence of all Clients. *Recognise the individual uniqueness of Clients, staff and visitors, and treat them with dignity and respect at all times. *Respect individual requirement for privacy at all times and treat all information relating to individuals in a confidential manner. *Recognise the individual need for personal fulfilment and offer individualised programmes of meaningful activity to satisfy that need of Clients and staff.

To set out the responsibilities of Care Clarity Support & Advocacy Ltd under The Health and Social Care Act 2008 (as amended) and Regulation 20: The Duty of Candour. Care Clarity Support & Advocacy Ltd will act in an open and clear way about Client care and treatment. To support Care Clarity Support & Advocacy Ltd in meeting the following Quality Statements:

Relevant Legislation

  • The Care Act 2014
  • Equality Act 2010
  • The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
  • Health and Social Care Act 2008 (Registration and Regulated Activities) (Amendment)

Regulations 2015

  • Mental Capacity Act 2005
  • Mental Capacity Act Code of Practice
  • Data Protection Act 2018
  • The Health and Social Care Act 2008 (Regulated Activities) (Amendment) Regulations
  • UK GDPR
  • Health and Care Act 2022
  • criminal Justice and Courts Act 2015

Roles Affected

  • all Staff

People Affected

  • Clients

Stakeholders Affected

  • Family
  • Advocates
  • Representatives
  • Commissioners
  • external health professionals
  • Local Authority
  • NHS

Care Clarity Support & Advocacy Ltd promotes a culture of being:

  • open
  • Honest
  • Transparent

Clients are provided with Care that is safe, effective and based on best practice. Where any incidents occur that may have the potential to cause harm, Care Clarity Support & Advocacy Ltd will act in a timely manner, investigating, reflecting, learning and, where appropriate to do so, sharing information to reduce the risk of reoccurrence. Care Clarity Support & Advocacy Ltd understands there are two types of duty of candour:

  • Statutory duty
  • professional duty

Care Clarity Support & Advocacy Ltd is regulated under the statutory duty of candour. however, certain groups of staff at Care Clarity Support & Advocacy Ltd may also fall under the professional duty of candour, including specific roles within the Nursing and Midwifery Council (NMC).

Where required, Care Clarity Support & Advocacy Ltd will be registered with the CQC for regulated activities, service types and service user bands as defined in the CQC Statement of Purpose. This will ensure that Care Clarity Support & Advocacy Ltd provides services that are safe, effective, caring, responsive and well-led in line with the CQC’s published quality statements, regulatory framework and associated best practice guidance. Domiciliary care service, personal Care The Registered Manager, and nominated individual of Care Clarity Support & Advocacy Ltd, have overall management responsibility for this policy and procedure and for ensuring the proper governance of Care Clarity Support & Advocacy Ltd. The Registered Manager role is held by: Linda Akli The nominated individual role is held by: Linda Akli

  • The organisation is managed and governed appropriately
  • Suitable systems are in place to effectively assess, monitor and improve the service
  • Records are completed accurately and stored safely and securely
  • That the UK General Data Protection Regulation (UK GDPR) and the Data Protection Act

2018 are met

  • Care and support delivered is consistent, safe and of high-quality

To meet the requirements of the duty of candour, Care Clarity Support & Advocacy Ltd must make public commitments to relevant persons to transparency, openness and fairness in relation to the care, support and treatment of Clients.

The relevant person must be notified in person as soon as possible, and this will be followed up with a written notification that includes:

  • A factual account of the incident
  • An apology
  • What further enquiries will be taking place
  • confirmation of when an update will be provided
  • A further notification, including an apology and details of the outcome of any further investigations Care Clarity Support & Advocacy Ltd will encourage a culture of openness and transparency by leading by example through its day-to-day actions and communications. Care Clarity Support & Advocacy Ltd will support employees at all levels to follow this commitment, ensuring that they are not obstructed to do so. Care Clarity Support & Advocacy Ltd will take action to remedy any incident of bullying and/or harassment related to the duty of candour.

Linda Akli will identify any notifiable safety incidents related to the duty of candour. CQC Notifications page, a link can be found in the Further Reading section. Any incident where an individual has been obstructed in carrying out their duty of candour will be investigated by Care Clarity Support & Advocacy Ltd. Care Clarity Support & Advocacy Ltd understands that some Clients may take in and retain information in different ways. To support full understanding and engagement, this policy is available in accessible formats. The accessibility tools tool has various ways of making this policy accessible by providing this policy in:

  • Audio
  • Large print
  • Multiple languages

This policy can also be made available in

  • Easy-read versions
  • Simple-policy view to reduce navigation and complexity

These options are in place to help Clients to understand and engage with this policy more easily.

  • all staff must be made aware of their personal responsibility to report incidents,

regardless of whether they are covered by the duty of candour

  • Each employee will be given the time to read and understand their roles and responsibilities that relate to the duty of candour at the point of induction
  • Duty of candour will be discussed at one-to-one discussions, supervisions, appraisals and staff meetings
  • Staff will be reminded through these communications that attempts by other staff to prevent them from reporting incidents is bullying and/or harassment, and that they must report this immediately to the most senior member of staff on duty (or if not appropriate, a senior manager within Care Clarity Support & Advocacy Ltd)
  • Staff will be reminded that if they are unsure whether the incident is reportable or not, it must be reported anyway Care Clarity Support & Advocacy Ltd ensures that an organisational training plan includes Duty of Candour within induction, mandatory and refresher training plans. additional role-specific training is also provided for those who may have additional roles and responsibilities.
  • all staff must report incidents defined in this policy in written form in a clear, accurate way that becomes a permanent record using the Incident and Accident Reporting Form, even if a verbal report has been made
  • The report must be made to the person on duty and in charge of the service at the time of the incident The person on duty then must formally report it to Linda Akli if they are not thesame person, as soon as possible

Linda Akli will

  • Carry out an initial assessment of whether the report includes details of a notifiable safety incident under the regulation (see section for more details). If the conclusion is yes, or borderline, continue with this procedure Inform Linda Akli or their representative of the incident report, and agree withthem who is the most appropriate person to continue the procedure. If Linda Akli- will takes over the role, they will continue the process using the following procedure
  • If it is considered that the incident is not a notifiable safety incident under regulation 20,

follow normal incident reporting procedures The CQC clearly defines a ‘notifiable safety incident’ as a specific term in the duty of candour regulation. It should not be confused with other types of safety incidents or notifications. A notifiable safety incident must meet all three of the following criteria:

  • It must have been unintended or unexpected
  • It must have occurred during the provision of a regulated activity
  • In the reasonable opinion of a healthcare professional, it already has, or might, result in death, or severe or moderate harm to the person receiving care (this will vary depending on the type of provider) If any of these three criteria are not met, it is not a notifiable safety incident but Care Clarity Support & Advocacy Ltd will still follow the overarching duty of candour to be open and transparent. Further information on Duty of candour: notifiable safety incidents is available on the CQC website. (A link can be found in the Further Reading section.) Care Clarity Support & Advocacy Ltd will use three questions in order to decide if an incident meets the notifiable incident requirements of the duty of candour (Regulation 20). Did something unintended or unexpected happen during the care or treatment? Did it occur during the provision of a regulated activity? Has it resulted in death or severe or moderate harm? The answer to all three questions must be ‘yes’ in order to meet the reporting threshold. Examples of notifiable safety incidents (duty of candour) are available on the CQC website. (A link can be found in the Further Reading section.)

As with all incidents, it is of utmost importance that this policy is used alongside the relevant external notification procedures to:

  • Ensure that relevant agencies are notified
  • If an investigation is required, that there is an understanding of roles and responsibilities

One or more suitable representatives of Care Clarity Support & Advocacy Ltd. will deliver (as soon as possible and in person) a notification of the incident to the relevant persons Care Clarity Support & Advocacy Ltd must ensure that the relevant person is given thesupport they need when receiving the information. depending on the needs of the individual, this may be the offer of an advocate or interpreter, or other communication aids

  • There must be a written record taken of the notification in person, which is kept securely by the Registered Manager, along with any other notes that are taken
  • An accurate account of the incident
  • An apology that the incident occurred. An apology is not an admission of liability, but an apology for the harm caused, regardless of fault, supports the duty of candour requirements
  • An offer to the relevant persons of sources of support and information which will assist them, where appropriate. This may include alternative support from within Care Clarity Support & Advocacy Ltd and external resources, such as advocacy and information services
  • Details of next steps, including timings

As soon as possible after the notification in person, a written notification will be sent or given to the relevant person containing the same information as above, plus:

  • The results of any enquiries made since the notification in person
  • Any further timescales
  • The results of any further enquiries and investigations must also be given or sent in writing to the relevant person if they wish to receive them

Linda Akli will assess the information they will need to carry out an

  • investigation, taking statements and gathering information needed
  • Having gathered all the evidence, an investigation must take place
  • all information and evaluation of the information will be recorded and kept securely in line with data protection legislation
  • The purposes of the investigation are to establish if the incident took place, define its nature, gather facts about the processes around the incident, and identify causes where possible
  • Prepare a statement to be given to the relevant person and representative stating the outcome of the investigation, remembering that duty of candour focuses on the transparency and openness of the organisation when such events occur
  • Include any lessons learned and changes made to the service because of the incident
  • The final statement will include a more specific apology as the causes of the incident will now be established
  • Where for any reason, the relevant person cannot be contacted, or after contact declines to communicate with Care Clarity Support & Advocacy Ltd, a written record of all attempts to contact them must be kept
  • all correspondence with the relevant persons must be recorded and kept securely
  • all correspondence should be written jargon free and where the need is identified,

support from an advocate will be offered to ensure the content is accessible to the individual receiving it

  • Reasonable support must be provided to the relevant person throughout the process
  • If a breach of candour is found to have occurred following investigation, and that this breach was by a professionally registered person, then that person will be reported to their professional registration body for further consideration
  • The same action will be taken if, during the investigation, it is found that a professionally registered person had obstructed another person in their professional duty of candour
  • If any individual believes that a breach of candour has taken place, they must report it to

Linda Akli

  • If an individual has been stopped or hindered in their duty of candour, they must report it to Linda Akli Linda Akli will conduct an investigation into the allegations and will report the findings to Care Clarity Support & Advocacy Ltd. for action if appropriateIf the allegation concerns Linda Akli, the individual must report the matter toCare Clarity Support & Advocacy Ltd. directly, who will carry out the investigation and take any action which may be required If the allegation concerns the actions of Care Clarity Support & Advocacy Ltd., the individualmust inform Care Clarity Support & Advocacy Ltd. and if action is not seen to be taken, the matter must be reported to the Care Quality Commission

Care Clarity Support & Advocacy Ltd provides care and support to Clients with a range of needs in a person-centred, safe, and lawful way. all staff must follow the guidance within this policy and the Client’s Care Plan, ensuring that assessed needs, reasonable adjustments and individual preferences are met.

  • Every Client is treated equally and with dignity and respect
  • Care and support are tailored to individual needs, preferences and desired outcomes
  • Staff follow legal, regulatory, and professional guidance at all times
  • Person-centred approaches are used to promote independence, choice, and wellbeing

To support this approach, staff will also follow the policies and procedures below where applicable:

  • Person-Centred Care and Supporting Planning
  • Raising Concerns, Freedom to Speak Up and Whistleblowing
  • Mental Capacity Act (MCA) 2005
  • Deprivation Of Liberty in Community Settings
  • Equality, Diversity and Human rights
  • Overarching Medicines Management
  • Positive Behaviour Support Including challenging Behaviour
  • Restrictive Practices Including Restraint and Physical Interventions
  • Sex, Sexuality and Relationships

This list is not exhaustive and there will be additional policies and procedures in place to support specific Client needs. Staff must seek clarification from their line manager or the Registered Manager, Linda Akli, if there is any uncertainty. Staff supporting any specialist area of need will receive appropriate induction and training. They will complete competency assessments, where required, to meet the needs of Clients as outlined in the Training Policy and Procedure at Care Clarity Support & Advocacy Ltd. To ensure Clients receive person-centred care and support from Care Clarity Support & Advocacy Ltd, staff must adhere to the following:

  • Regulation 20 (9) in relation to any other provider other than a Health Service Body: in relation to any other registered person, “notifiable safety incident” means any unintended or unexpected incident that occurred in respect of a Client during the provision of a regulated activity that, in the reasonable opinion of a health care professional, appears to have resulted in:
  • The death of the Client, where the death relates directly to the incident rather than to the natural course of the Client’s illness or underlying condition
  • An impairment of the sensory, motor or intellectual functions of the Client which has lasted, or is likely to last, for a continuous period of at least 28 days
  • Changes to the structure of the Client’s body
  • The Client experiencing prolonged pain or prolonged psychological harm
  • The shortening of the life expectancy of the Client
  • In Regulation 20, “relevant person” means the person using the service or, in the following circumstances, a person lawfully acting on their behalf:
  • When the person using the service dies
  • Where the person using a service is under 16 and not competent to make a decision in relation to their care or treatment, or
  • Where the person using the service is 16 or over and lacks capacity to make decisions
  • (CQC Provider Guidance)
  • Any person who uses the service harmed by the provision of a service provider is informed of the fact and an appropriate remedy offered, regardless of whether a complaint has been made or a question asked about it
  • (CQC Duty of Candour Guidance)
  • allowing information about the truth about performance and outcomes to be shared with staff, people who use the service, the public and regulators
  • Enabling concerns and complaints to be raised freely without fear and questions asked to be answered
  • (CQC Denition)
  • ‘Reasonable support’ will vary with every situation, but could include, for example:
  • Environmental adjustments for someone who has a physical disability
  • An interpreter for someone who does not speak English well
  • Information in accessible formats
  • Signposting to mental health services
  • The support of an advocate
  • drawing their attention to other sources of independent help and advice such as

AvMA (Action against Medical Accidents) or Cruse Bereavement Care

  • (CQC Denition)
  • Harm that requires a moderate increase in treatment, including re- admission, prolonging of care, admission to hospital, referral to hospital as an outpatient, cancelling of treatment that is otherwise needed, or transfer to another specialist facility or treatment area
  • Moderate harm also includes significant (but not permanent) harm
  • A permanent lessening of bodily, sensory, motor, physiologic or intellectual functions, including removal of the wrong limb or organ or brain damage, that is related directly to the incident and not related to the natural course of the Client’s illness or underlying conditionAn unplanned return to surgery, an unplanned re- admission, a prolonged episode of care, extra time in hospital or as an outpatient, cancelling of treatment, or transfer to another treatment area (such as intensive care)
    • Pain which a Client has experienced, or is likely to experience, for a continuous period of at least 28 daysPsychological harm which a Client has experienced, or is likely to experience, for a continuous period of at least 28 days
    • Staff will not be stopped from reporting incidents. If staff are prevented or discouraged,

    this will be investigated Care Clarity Support & Advocacy Ltd will support staff if they need to be involved in anotifiable incident

    • Other staff may be asked to support the relevant person when they receive a notification if they are the best person to do this
    • It is everybody’s responsibility to report incidents. Staff will report incidents on the appropriate form to the person in charge
    • If things go wrong and a notifiable safety incident occurs, the relevant person needs to be notified in person as soon as possible and this must be followed up by a written notification. Both must include the facts about what has happened, an apology, what the next steps are and timescales Care Clarity Support & Advocacy Ltd will use three questions in order to decide if anincident meets the notifiable incident requirements of the duty of candour (Regulation 20) Care Clarity Support & Advocacy Ltd has a duty to be transparent and open about theClient’s care, support and treatment
    • You may get further information before the end of the process. It is up to you whether you want to have that information. Care Clarity Support & Advocacy Ltd will respect what you want to do and will make a note of it for their records nished, Care Clarity Support & Advocacy Ltd will tell you what
    • When the process has happened, and what they are going to do to make it right
    • As the provider of the service we have assessed your information needs. We will make sure you have the right help for you to understand the information you receive
    • You will receive a letter which may be given or sent to you in the post (which tells you the same information) shortly after you are told. It will also give you any further dates or information on what has happened since When Care Clarity Support & Advocacy Ltd tells you, they need to tell you certain things.
    • These are the facts of what happened, what will happen next, and they will also give you an apology The law says that Care Clarity Support & Advocacy Ltd will tell you if things go wrong withyour care, support or treatment, and you are hurt. The provider must tell you what has happened Care Clarity Support & Advocacy Ltd will offer you support to understand this at the timethey tell you, and throughout the process
    • Improvements and changes made due to Notifiable Safety Incidents are shared with relevant persons Transparency is embedded in the culture at Care Clarity Support & Advocacy Ltd and thesame procedures to notify relevant persons are used, even when the threshold for Regulation 20 is not met in regard to the level of harm caused

    The following forms are included as part of this policy

    • Initial Notification to Relevant Persons Regarding Duty of Candour – AR38 When a notifiable safety incident occurs and triggers Regulation 20 Duty of Candour.

    Suggested template initial notification letter. Transfer to your own letterhead, format and edit as required where indicated. PLEASE NOTE: If the notification is addressed to a relevant person who is not the service user involved as per the policy, please edit accordingly.

    [Date]

    Dear [the relevant person],

    Notification under the Duty of Candour Regulations

    I am writing to you to inform you of an incident which has occurred involving you/, [insert Client’s name]. The details of the incident, as they are known at the time of writing this letter, are:

    Date: ________________ Time: ________________ Location: ________________

    Nature of the incident: [describe the incident, not naming persons involved (other than the Client) if possible, taking into account the definitions of an

“incident” as set out in the policy section of this policy and procedure.] I am sorry that this has happened to [you/Client’s name]. I have begun the process of conducting an investigation into the incident.

As part of the investigation, I expect to interview

  • [List people by post or function, avoiding names if possible]

I will also be gathering the following information

  • [List the information you are planning to gather and review only if relevant]

I will be making arrangements to support you during the investigation, and also in response to the effects this may have had on you. [Edit as appropriate, and detail the support to be offered]

I will give you further information by [date] and will inform you if this date changes. This may only be interim information if I have not completed my investigations, in which case I will give you a predicted date for the end of the investigation. If these target dates cannot be met because of issues which I am currently unaware of, I will contact you to let you know reasons for the delay, the progress to date, and revised dates.

Yours sincerely,

Registered Manager