Reducing the Risk of a Closed Culture

Scope of this chapter

A closed culture is “a poor culture that can lead to harm, including human rights breaches and organisational abuse”. 

Closed cultures can develop unintentionally or intentionally.

An unintentionally closed culture usually develops slowly over time, creeping up on staff and gradually becoming ingrained without anyone really noticing anything is wrong.

An intentionally closed culture is where poor practice is innate and takes place routinely and deliberately across the whole service.

Closed cultures have been identified in many serious case reviews, most notably that of Winterbourne View.

This chapter explains the key signs and indicators of a closed culture - by knowing this we can take early and preventative action to stop such a culture from ever developing. It also describes some of the things we can do to always promote an open culture.

Relevant Regulations

Related Chapters and Guidance

There are four main features of a closed culture. When they are present, chances are a closed culture exists:

  1. Staff and/or managers no longer see the people being supported as people;
  2. Most people being supported no longer speak up for themselves;
  3. Increased incidents of near misses and poorly managed risk;
  4. Increased incidents of intentional or unintentional abuse, human rights breaches and care/treatment errors.

The following are examples of some of the behaviours that could indicate a closed culture:

Caption: Examples of closed culture behaviours

The service is run for the benefit of the staff, not the people being supported. For example, daily routines are fixed and not flexible, cultural needs that require the service to adapt are not catered for.

Practices promote segregation, restriction, restraint, seclusion and other forms of punishment or undignified treatment.

Personal care is carried out in an undignified way, with little or no regard for privacy.

People are not supported to make choices, or choices are very restrictive and not in line with needs and preferences.

People are not believed if they speak out, or face retaliation of some sort for doing so. For example, being denied something or threatened with harm.

Staff talk openly about the people being supported, with no regard for confidentiality or the words they use to describe the person.

Staff do not seek consent before carrying out support.

There are cliques amongst the staff team - some staff feel isolated.

Staff spend more time talking to each other than engaging with the people being supported.

There have been no records of accidents, injury or incidents for some time, indicating a lack of reporting and record keeping.

Training, induction and recruitment checks are not in place.

Supervision does not take place, or very rarely.

There is a high turnover of staff and/or managers.

Visitors to the service are discouraged and not made to feel welcome.

If any of the following are happening in the service, there is an increased risk that a closed culture could develop.

People are experiencing poor care

Risks are further increased when the people being supported are very vulnerable, less likely to recognise that the behaviour towards them is wrong, and unable to speak up for themselves due to complex communication needs or any other factor. It is all too easy for staff to take advantage of this vulnerability and provide poor care, knowing the person will not or cannot tell anyone.

Management and leadership are weak

Weak management and leadership increase the likelihood that poor practice will go unnoticed or unchallenged. Good staff may quickly become demoralised and leave. Trust, openness and transparency can also be lost.

Staff are not skilled, knowledgeable or experienced

If staff are not skilled or knowledgeable, care and support is likely to be unsafe. There is also likely to be a lack of knowledge about core values and principles, such as dignity and respect.

The service has limited interaction with the outside world

This can isolate the person and lead to further issues such as depression, boredom, no one checking what is going on, no outside support for the person, behavioural issues etc. Family and friends also have no idea how the person is being supported or cared for.

To counter the risk of a closed culture, we must all act in ways that promote an open culture. Any staff member that does not feel we are promoting an open culture should bring this to the attention of a manager or the registered person.


The person should be involved in the service, including how it is run and what can and should be provided for them. Their views should be sought frequently in different ways. Advocacy or representation from family and friends should be made available when needed.

See: Participation and Advocacy

Family and friends

Family and friends should be welcomed, and we should make sure that they have time with their loved ones on their own. Family and friends must be kept informed, so they feel included in the care and support provided.

Physical Environment

The physical environment should meet all the health and safety requirements of the service and the person. The physical environment should promote independence and not be used to increase restrictions or reduce choice. For example, only allowing access to one room.

Access to the community

People should be supported to access and be a part of the wider community. This can open opportunities for growth, combat loneliness, break down stereotypes and offer stimulation. It can also reduce behaviourial issues and increase self-esteem and confidence.

See: Accessing the Community

Good Record Keeping

All records around medication, incidents, finances, safeguarding, accidents and deaths should be properly recorded, in line with the requirements of any relevant regulations. Records should be reviewed to identify any patterns and issues that may be emerging.


Relevant others should be informed of any incidents, changes and issues in a timely way and in line with relevant regulations. The service should welcome external advice, guidance and feedback. For example, from the CQC, the local authority or a health professional.


All training requirements should be identified quickly, and staff should be able to raise a training need directly. Ongoing competency should be monitored.


Good clear recruitment policies should be in place to ensure that staff have the right disposition and character to work in social care. All relevant checks should be made to ensure potential staff do not have a history of concerning behaviour towards others.

A good induction should be provided for all staff.

Staff should feel valued and supported. They should be able to recognise poor practices, feel confident about raising concerns to managers, and be assured that those concerns will be properly investigated, and poor practices addressed. 

Staff should always speak to the people we support and each other in a courteous and respectful manner. On no account should abusive, discriminatory or offensive language or behaviour be used.

Staffing Levels

Staffing levels should reflect the number and needs of people being supported. 

Staff should not be under pressure due to shortages.

Policies and Procedures

All policies and procedures should be followed and kept up to date.

An effective whistleblowing policy should be in place, and staff should be confident to use it if they need to, without the fear of retribution.

See: Whistleblowing

A well-led service

Managers should lead by example and act in a manner that others can follow.

Staff should be encouraged to learn and develop their skills and knowledge.

Good practices should be recognised and celebrated.

Regular supervision should be offered and of a high quality.

Staff collaboration should be evident and valued.

Managers should be open to feedback and suggestions for service improvement.

Staff should be encouraged to raise poor practice. Complaints should be properly investigated, and lessons learned and shared as a team.

See: Learning from Safeguarding Enquiries, Safety Incidents and Complaints

Discrimination and bullying should be dealt with appropriately and in a timely manner.

Where a staff member is found culpable of poor practice, managers should not be afraid to use proportionate human resources procedures at their disposal to discipline or dismiss.

Last Updated: June 8, 2022