This is a legal requirement as set out in the Health, (Tobacco, Nicotine etc and Care) (Scotland) Act 2016 and The Duty of Candour Procedure (Scotland) Regulations 2018, to ensure that if something goes wrong in health or social care services that the people affected are offered an explanation, an apology, and an assurance that staff will learn from this error. Learning is shared with the people affected, within the organisation, and across the sector as required.

The purpose of the Duty of Candour is to ensure organisations are open, honest and supportive when there is an unexpected or unintended incident resulting in death or harm. We must activate the Duty of Candour procedure as soon as reasonably practicable after becoming aware that:

• An unintended or unexpected incident occurred in the provision of the health, care or social work service provided by the organisation as the responsible person;
• In the reasonable opinion of a registered health professional not involved in the incident:
  • that incident appears to have resulted in or could result in any of the outcomes outlined in the table below; and
  • that the outcome relates directly to the incident rather than the natural course of the person’s illness or underlying condition.

2021-22 Report

It is a requirement that we produce an annual Duty of Candour Report as below:

Type of unexpected or unintended incident	Number of times this happened
Someone has died	0
Someone has permanently less bodily, sensory, motor, physiological or intellectual functions	0
Someone’s treatment has increased because of harm	0
The structure of someone’s body changes because of harm	0
Someone’s life expectancy becomes shorter because of harm	0
Someone’s sensory, motor or intellectual functions is impaired for 28 days or more	0
Someone experienced pain or psychological harm for 28 days or more	0
A person needed health treatment in order to prevent them dying	0
A person needed health treatment in order to prevent other injuries	0

During the period 1st April 2021 – 31st March 2022 zero incidents triggered the Duty of Candour.

Our Training, Policy and Procedure

Cornerstone’s policy is that all colleagues undertake the Duty of Candour e-learning module, which has been available on Kallidus, our training system, since May 2018. Training statistics are monitored monthly, shared across the organisation and reminders about this e-learning are given regularly via our weekly internal communication bulletin. As of 31st March 2022, 95% of current colleagues had completed this training with 100 people (5%) still to do this. This figure includes 83 new colleagues (4%) who are required to complete this course over their first six months, before they can pass their probationary period. This leaves 17 (1%) of colleagues who are yet to complete the course and have been with us over six months. A number of these people are on long term absence or not working currently and several are only just over the six months. Completion rates are consistent with the 95% a year ago, demonstrating continued training completion within the organisation.

We have a Duty of Candour policy and checklist which were revised in March 2021 and will be reviewed again later this year. These are available to all colleagues via our Microsoft Teams platform. Should an incident occur which triggers implementation of Duty of Candour, the relevant colleague will notify their Branch Leader and the Director of Delivery. The incident will be recorded and reported as per organisational guidelines. The registered manager of the service will also notify the Care Inspectorate, whose reporting processes include consideration of Duty of Candour.

Our external and confidential 24/7 support service (AXA BeSupported) is available to all colleagues and will be promoted if Duty of Candour is triggered. A Cornerstone Leader will meet with those involved to review the incident, identify required action and ongoing learning. Where appropriate, our external Health and Safety Consultant will also be involved.

Learning will be identified as a result of the incident along with any further actions required such as additional training. Our Quality and Service Delivery Committee of the Board of Directors will be kept updated on any Duty of Candour incidents.

Where the incident arises from the action or omission of a Cornerstone colleague our disciplinary policy may be implemented as appropriate. We would also inform other agencies such as the police or SSSC as needed.

What have we learned?

In order to implement this statutory Duty of Candour we have made e-learning on this subject mandatory for all colleagues and reviewed our internal policies and guidelines.

We have identified the need to monitor training statistics regularly to ensure completion, and issue regular reminders to colleagues. We are working to improve the figures of those who have been with us over six months but have not completed this essential eLearning. This will include exploring why this situation has occurred and sending personal tailored reminders.

We have also identified the need for colleagues to talk over events which may trigger Duty of Candour. This has stemmed though queries following incidents this year, two of which were Covid related. We intend to review the wording of our policy to ensure it is clear and continue to encourage open discussions over potential Duty of Candour situations as a learning for all. We also continue to follow the philosophy of the duty about being open and honest and learning from mistakes, whether or not they trigger the Duty of Candour formally.

If you would like more information about this report, please contact the Quality Improvement Team on [email protected] or 0300 131 333 option 1 then option 7.

Click here for the downloadable version of our Duty of Candour Report 2021 - 2022

Duty of Candour Report 2020 - 2021

Duty of Candour Report 2019 - 2020