Devon Partnership NHS Trust

Updated 2 October 2023

We carried out this unannounced, comprehensive inspection of the acute wards for adults of working age and psychiatric intensive care unit (PICU), community services for adults of working age and forensic inpatient/secure wards of this trust as part of our continual checks on the safety and quality of healthcare services. At our last inspection we rated the trust as good overall.

Following this inspection, we rated the trust good overall. In addition, we rated each of the key questions - safe, effective, caring, responsive and well-led as good overall.

During this inspection we inspected three of the Trust’s core services and rated one as good (acute and PICU) and two as requires improvement (community mental health services for adults and forensic inpatient/secure wards).

We also undertook an inspection of how ‘well-led’ the trust was. Overall we rated safe, effective, caring, responsive and well-led as good.

Devon Partnership NHS Trust delivers mental health and learning disability services from community and hospital based settings across Devon and the south west. It was formed in 2001.

The trust serves a population of approximately 894,000 residents covering an area of 2600 square miles. The trust covers an area that is predominantly rural with areas of urban development along its north and south coastlines. Life expectancy for both men and women is higher than the England average. There is a significantly higher rate of people aged 65 and over in Devon compared to the England average. The trust is commissioned to provide services by NHS Devon Clinical Commissioning Group (CCG) and Bristol CCG. The trust works in partnership with other organisations to deliver its services including Devon County Council and Torbay Unitary Authority, as well as a number of third sector organisations. The trust had also been transferred commissioning responsibilities for the medium and low secure mental health care of adults in the South West region in October 2020. The trust led the South West Provider Collaborative. The Collaborative had eight partners, including five NHS organisations, one community interest organisation and two independent hospitals. This arrangement gave responsibility to the trust for commissioning the care of over 350 adults with medium and low secure mental health needs. The geographical area was vast and ranged from Cornwall to Gloucester (a catchment population of over five million people.

The trust provides the following services

• community based services for adults of working age
• long stay/ rehabilitation wards for adults of working age
• forensic inpatient and secure wards
• acute wards adults of working age and PICU
• wards for people with learning disability or autism.
• mental health crisis services and health-based place of safety
• community based services for older people
• wards for older people with mental health problems
• community based services for adults with a learning disability or autism
• child and adolescent community mental health services
• perinatal Mental Health Community and inpatient services
• eating disorder service
• specialist gender identity clinic
• personality disorder service
• substance misuse services (Torbay only)
• mother and baby mental health unit

Our rating of services stayed the same. We rated them as good because:

• We rated safe, effective, caring and responsive as good. We rated well-led for the trust overall as good.
• We rated acute wards for adults of working age and psychiatric intensive care unit as good. This had improved from the rating of requires improvement given at our last inspection. We rated community-based mental health services for adults of working age as requires improvement. This had improved from inadequate given at our last inspection. We rated forensic inpatient/secure services as requires improvement, this has gone down from the outstanding rating given following our inspection in December 2017. In rating the trust overall, we included the existing ratings of the nine previously inspected services.
• Since the last inspection the board had appointed a new chair and two new non-executive directors. The trust had also appointed a new Executive Director of Nursing and Professions and to a new post which has been created, Director of Corporate Affairs. The previously vacant Deputy Chief Executive post had been combined with the existing Executive Director of Finance and Strategy and an interim Medical Director was in post.
• The chair, non-executive directors and executive directors provided high quality, effective leadership. We found an ambitious board, with a wide range of skills and experience who demonstrated dedication and commitment to improving the care delivered to patients. The non-executive directors all had experience as senior leaders in a range of occupations and organisations and brought a wide range of skills such as a knowledge of finance, strategic development, legal, information technology, working in partnership and transforming services. The non-executive directors were well supported and provided appropriate challenge to the trust board.
• The trust reviewed leadership capability and capacity regularly. An organisational development review had recently been undertaken. The trust were considering separating some of the executive portfolios and appointing additional executives to the board. The board recognised they needed to strengthen and add capacity to achieve the future vision and new strategy which was due to launch in October 2021.The trust had invested in developing its leaders at all levels and we saw effective leadership throughout the services of the trust.
• There were regular board visits to services by executives and non-executives. These visits had continued during the pandemic to remain connected with frontline staff. Senior staff across the trust modelled open and transparent behaviours. Staff we spoke with during the core service inspections felt supported, valued and respected.
• The trust leadership demonstrated a high level of awareness of the priorities and challenges facing the trust and how these were being addressed. The trust leadership had demonstrated an ability to adapt at a fast-changing pace during the COVID-19 pandemic. The trust’s information technology provision had been expanded quickly during the pandemic. The trust provided staff with IT equipment to work remotely and usage had risen by 600%. The trust had acted quickly to ensure remote working was embedded and implemented software such as Attend Anywhere and electronic prescribing to assist with patient contacts. The trust were one of the highest users of Attend Anywhere nationally.
• The senior leadership team, service leaders and staff throughout the trust were open and transparent. The trust had a clear set of visions and values which staff understood. The trust strategy had been due to be refreshed in March 2021. A decision had been taken to extend this until October 2021 due to the pandemic. This risk associated with this delay had been identified and control measures were in place to ensure delivery of the new strategy. Leaders were well cited on the ambition of the new strategy and there was a focus on aligning the strategy with both local and national priorities.
• The trust had revised the governance structure in October 2020 and introduced a new Quality Governance Assurance Committee which is a Committee of the Trust Board. The board was supported by five other Committees including the Audit Committee. There were clear lines of accountability and governance arrangements in place to provide ward to board assurance. The board met regularly and had a clear agenda for discussion. Papers that were presented and reviewed at board were detailed and to a high standard. Committee discussions were robust and provided escalation when required. The new Board Assurance Framework had recently been implemented. The board regularly discussed board assurance, quality, safety, workforce delivery, strategy, transformation, finance and commissioning.
• There were a range of mechanisms in place for identifying, recording and managing risks, issues and mitigating actions. The trust managed risk robustly in accordance with the Risk Management Framework. Individual services maintained their risk registers which were submitted to the trust’s electronic risk management system. All staff had access to the risk register and were able to escalate concerns when required. Staff concerns matched those on the risk register.
• The trust continued to be financially stable and had strong financial expertise among the executives and NEDS.
• The trust had responded positively to previous inspection findings in 2019 and 2020. For example, we saw clear improvements in the way the community mental health teams for adults of working age monitored patients on the waiting lists to keep them safe and respond to changing risks. A central wait list management team had been established and monitored patients on the waiting list. Improvements had also been made to environmental safety and ligature management in the acute wards and psychiatric intensive care unit. Following a number of serious incidents, the trust had introduced simulation training in ligature risk assessment and management with over 100 staff being trained. The trust had also strengthened the engagement and observation policy and changed and improved practice in response to serious incidents. These actions demonstrated how the trust had learned from and responded to risks across the trust.
• The trust leadership team had actively engaged with staff. The trust had introduced a new People Together Programme Board. The board planned to receive reports from each directorate during the summer months to review how the staff survey feedback had been used to inform improvements locally and celebrate achievements of teams at a local and directorate level. The People Together Programme continued to build on work completed in 2020 against the NHS People Plan. The aim of the programme was to improve the experience of everyone working at the trust.
• The board were committed to quality and inclusion. There was an active focus on equality, diversity and inclusion represented at board level. There were several staff networks who met regularly. These included Black Minority Ethnic (BME) staff network, Staff Carers (including pregnancy and parents) network, LGBTQI+ staff network, Disability, impairment and long-term health conditions staff network, Neurodiversity staff network and the menopause matters staff network.
• The trust was working with other providers in the strategic development of mental health services within the Integrated Care System (ICS). The ICS Mental Health Care Programme Board was chaired by the CEO of the trust. The trust board regularly discussed joint working with the ICS.
• The trust wide vacancy rate had reduced significantly since our last inspection. The trust had undertaken widescale recruitment during the pandemic. Workforce transformation programmes had supported recruitment of staff from overseas and electronic on-boarding.
• The trust were engaged with the wider health economy and system locally. During the pandemic the trust had provided support to other organisations locally and established urgent assessment hubs in Exeter, Torbay and North Devon to divert people from A&E. The trust had worked hard to support staff during the pandemic and also extended this welfare offer to partner agencies.

However

• Some staff in the forensic services and the community mental health teams expressed concerns about speaking up and raising concerns to senior leadership. Some staff in both services said they were reluctant to speak about their concerns because of fears of reprisals.
• Whilst the trust had a workforce strategy and the vacancy rate had reduced to 2% overall trust wide there were a high number of nursing vacancies (39%) in the forensic inpatient and secure services.
• Staff in the forensic inpatient and secure services used the National Early Warning Score 2 (NEWS2) tool to identify deteriorating patients. We found gaps in the recording within clinical records which included missed entries, missing signatures and total scores not calculated. We found examples where a patient’s deteriorating health should have been escalated but this had not been recorded or documented in line with national guidance. In two examples the NEWS2 indicated patients had high heart rates but there was no evidence of escalation or of observations being repeated. Another patient had a NEWS2 score of five. Evidence provided by the trust showed physical health observations had been undertaken, however, the process of escalation of the NEWS2 score was not escalated correctly and was a near miss.
• The care plans in the forensic services varied in quality. Care plans were inconsistently completed and were not all personalised, holistic or recovery orientated. Care plans did not all reflect patient’s involvement.
• Waiting times in the community mental health teams for adults of working age were above the national target of 18 weeks. Of the 18 community mental health teams, 15 had waits of longer than the national target. The average length of time patients were waiting for allocation of treatment was 32 weeks. Waiting times for psychological therapy in the community mental health teams for adults of working age were long. The average wait to be seen by the psychology teams was over a year.
• Physical healthcare monitoring for patients in the community mental health teams for adults of working age was inconsistent. For example, the team in Exeter had electrocardiogram (ECG) machines and staff trained to use them. However, the team in Torbay did not have ECG machines. Some teams were unable to take bloods on site, whereas others could. Whilst some teams had physical health clinics that were up and running, other teams did not. This meant that patients had differing physical health monitoring depending on which team they were under, meaning an inconsistent service across Devon. The Trust was aware of the inconsistencies in physical health practice across services, and had established a physical healthcare transformation programme and was in the early stages of implementation'

How we carried out the inspection

We used CQC’s interim methodology for monitoring services during the COVID-19 pandemic including on site and remote interviews by phone or online.

We visited 10 of the trust’s 18 community based mental health teams. For adults of working age and psychiatric intensive care units we visited all of the trust’s wards. For forensic inpatient/secure services we visited all seven of the trust’s wards.

During the community mental health teams inspection, the inspection team:

• visited the premises where teams were based and looked at the quality of the service environment.
• spoke to 10 team leaders and one Community Service Manager and one Locality Manager
• spoke with 14 patients who used the service
• interviewed 22 staff including nurses, senior mental health practitioners, support workers, occupational therapists, clinical psychologists, social workers, consultant psychiatrists, and administrative staff
• reviewed 43 care records of patients
• reviewed 13 medication records of patients and five physical health monitoring forms
• observed one multi-disciplinary meeting and one allocation meeting and
• looked at policies, procedures and other documents relating to the running of the service.

For the adults of working age and PICUs inspection, the inspection team:

• visited all wards at the hospital sites, looked at the quality of the ward environments and observed how staff were carding for patients
• spoke with 21 patients who used the service
• spoke with the managers or acting managers for each of the wards
• interviewed 18 staff including nurses, support workers, occupational therapists, psychologists, pharmacists and doctors
• reviewed 29 care records of patients
• reviewed 21 medication records of patients
• attended various ward activities including handovers, multidisciplinary meetings and patient activity groups
• looked at policies, procedures and other documents relation to the running of the service.

For the forensic inpatient/secure services inspection, the inspection team:

• visited all wards at the hospital site, looked at the quality of the ward environments and observed how staff were carding for patients
• spoke with 14 patients who used the service
• spoke with the managers or acting managers for each of the wards
• interviewed 26 staff including nurses, support workers, occupational therapists, psychologists, pharmacists and doctors
• reviewed 15 care records of patients
• reviewed 15 medication records of patients
• attended various ward activities including handovers, multidisciplinary meetings and patient activity groups
• looked at policies, procedures and other documents relation to the running of the service.

You can find further information about how we carry out our inspections on our website: www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

What people who use the service say

Patients told us that staff treated them with compassion and kindness. They said that staff respected patients’ privacy and dignity. Patients said staff were attentive, non-judgemental and caring. Patients also reported staff provided help, emotional support and advice when they needed it. Patients said staff treated them well and were responsive to their needs.

Updated 27 May 2025

We carried out an unannounced, focused, responsive inspection of the forensic inpatient and secure wards at Langdon Hospital. This inspection was undertaken in response to concerns raised by both internal and external sources regarding the safety of people using the service and the effectiveness of leadership within the service.

At our previous inspection in 2021, we rated the service as Requires Improvement overall. This included the key questions of Safe, Effective, and Well-led.

During this inspection, we visited all 5 wards at Langdon Hospital to assess the quality and safety of care being provided. We focused our assessment on the key questions of Safe, Effective, and Well-led.

Following this inspection, we have again rated the service as Requires Improvement overall. Each of the key questions assessed were also rated as Requires Improvement.

We identified 5 breaches of the regulations. These related to person-centred care, dignity and respect, safe care and treatment, good governance, and staffing.

As a result of breaches relating to good governance and, safe care and treatment, we issued a Warning Notice under Section 29A of the Health and Social Care Act 2008 which required the service to make significant improvements to the quality of the health care they provided.

Additionally, where concerns did not meet the threshold for inclusion in the Warning Notice, we have asked the provider for an action plan in response to the concerns found at this assessment.

Devon Partnership NHS Trust, established in 2001, is a specialist mental health provider, delivering mental health, learning disability, and neurodiversity services from community and hospital-based settings across Devon and the broader Southwest region.

The trust serves a population of approximately 953,800 residents covering an area of 2600 square miles. The trust covers an area that is predominantly rural with areas of urban development along its north and south coastlines.

In October 2020, the trust assumed the role of lead provider for the Southwest Provider Collaborative (SWPC), a regional partnership responsible for commissioning services including those of forensic and secure mental health. This involved the trust taking on commissioning responsibilities for the care of approximately 350 adults with medium and low secure mental health needs. The Collaborative had 8 partners, including 5 NHS organisations, 1 community interest organisation and 2 independent hospitals. The geographical area was vast covering approximately 9,266 square miles, spanning from the Isles of Scilly to Gloucestershire (a catchment population of over 5 million people).

During our inspection, people using the service told us they did not always feel involved in decisions about their care or risk assessments. Care plans often lacked evidence of person-centred care and did not reflect individuals’ current needs. In some cases, staff used a specific risk assessment tool inconsistently, leading to restrictions that people using the service experienced as unfair or punitive.

The ward environments included blind spots that staff had not formally assessed or mitigated. The design of seclusion and extra care areas did not always protect people’s privacy or dignity. Staff told us they were not always sure what happened after incidents, and staff also said they were not clear on how learning was shared or acted upon.

Staff found it difficult to use the trust’s digital systems to record or access care information effectively. They also had not received training in how to assess or manage non-clinical risks. Many staff lacked awareness of ligature risks, and the tools available did not help them to identify or prioritise those risks. Staff had not received the enhanced training needed to effectively care for autistic people, despite people with those needs being supported on the wards.

Staff also told us there were not always enough staff to meet people’s needs, especially during busy or unpredictable periods of increased acuity. This made it harder to maintain specialist roles and deliver consistent care to people.

However, since our last inspection, in response to a requirement notice we had issued, we found the trust had taken action to improve the monitoring of people’s physical health. Staff now completed this documentation more accurately and consistently, which enabled them to identify early signs of deterioration. As a result, they were able to take timely and appropriate action to support the health and wellbeing of people using the service.

The Occupational Therapy programme received strong praise from people who used the service, who told us it felt valued and had a positive impact on their care and treatment.

Staff across the service demonstrated openness and a willingness to speak up. There was a strong sense of transparency and a supportive team culture.

Staff in developmental roles, including Nursing Associates and those on Nursing Apprenticeship pathways, were being given opportunities to grow and develop their skills within the service.

Overall, people using the service expressed significant frustration with the pace of their care and treatment, particularly the perceived lack of progress within the care pathway and delays in discharge planning. Many people using the service felt their care plans did not reflect their personal goals or were not shared with them in a meaningful way.

Access to staff, including doctors, was reportedly inconsistent, with some people using the service reporting positive relationships and regular reviews, while others described difficulty in accessing medical staff and having a lack of involvement in treatment decisions. People using the service frequently reported perceived staff shortages impacted their access to leave and activities, which to them were highly valued aspects of their care experience.

Communication was a recurring theme of concern. People using the service described inconsistent messaging, lack of transparency around care decisions, and a general sense that their voices were not being heard. Some people using the service reported fear of retaliation for raising complaints, and several described the complaints process as ineffective or inaccessible.

The use of a specific risk assessment tool was widely criticised. People using the service felt it was being used punitively, without explanation or discussion, and that it contributed to the loss of leave or privileges without due process. There was a strong perception that restrictions were applied inconsistently, and people using the service felt these were petty or overly rigid.

Despite these concerns, people using the service consistently praised the Occupational Therapy (OT) team and some individual staff members for their dedication and support. The OT team was credited with enabling much of the leave that people were able to access.

However, people using the service we spoke with reported feeling physically safe and described the environment as clean and well maintained.

Updated 12 September 2024

We carried out a responsive onsite assessment following information of concern received from various external sources relating to patient safety and leadership. We undertook onsite visits between March and October 2024. We visited Haytor Ward, Salus Ward, Delderfield Ward, and The Junipers, to inspect the care being provided under the key questions Safe and Well-led. These key questions were rated good following our previous inspection in 2021.

We found the Trust had appropriate leadership structures in place and were working to address staffing issues within the service and adopted more aligned ways of working across the various wards. Staff kept patients safe and understood their roles and responsibilities. During the previous inspection, a breach of regulation was identified under regulation 12 (safe care and treatment) relating to ligature risk assessments. Staff have undertaken ligature risk management training and were able to explain understanding of known risks on the wards, this meant the previous breach of regulation 12 was now met.

However, we found that the Trust had not completed their own action plan to improve ligature risk assessments across the wards. Ligature risk assessments remained generic and not individual to the ward they related to. This meant staff unfamiliar with the wards would not know explicit mitigation for each identified ligature risk.

The Trust was issued a requirement notice under regulation 17 of the Health and Social Care Act 2008 (regulated activities).

Following this inspection, senior leaders took action to address this quickly and worked with other external organisations to improve their ligature risk management approach.

Updated 7 October 2025

The Additional Support Unit (ASU) was run by Devon Partnership NHS Trust, and was located on the outskirts of Exeter in the grounds of Whipton Hospital. The ASU was a specialist inpatient assessment and treatment service for up to 5 people aged 18 years and over with learning disabilities and mental health problems whose needs could not be met within mainstream services, despite reasonable adjustments.

On 14 November 2024 we undertook an unannounced, responsive inspection of the ASU to check whether the improvements that we told the trust to make after our last inspection in March and April 2024 had been made. Following our last inspection in March 2024, we placed conditions on the provider, telling them to reduce the number of patients admitted to the ASU and preventing them from admitting more patients. At the time of this inspection, the Care Quality Commission had limited the ASU to 3 patients.

At the time of the inspection the trust told us that they planned to close the ASU and open a new purpose built inpatient unit for people with mental health needs and a learning disability or autism.

Updated 2 October 2023

The Haldon is a specialist eating disorder service that helps treat people with severe eating disorders provided by Devon Partnership NHS Trust and a partner of and is commissioned by the South West Provider Collaborative (SWPC). The Haldon is located within Wonford House, Exeter.

The Haldon provides care for people who require admission to a specialist unit as part of their longer term care plan for eating disorders.

The Haldon opened in 2006 and provides support for 10 patients at any one time as inpatients. The service is aimed at people with severe eating disorders and provides care on a residential basis.

The Haldon currently provides 10 bed spaces for people requiring intensive treatment. This is a mixed ward and complies with the single sex accommodation. At the time of this inspection there were only five patients on the ward whilst three patients were on leave at the time of our inspection, who were all under section.

The Haldon has the Quality Network for Eating Disorders (QED) accreditation from The Royal College of Psychiatrists.

This was the first time we inspected the eating disorder service. We rated them as ​requires improvement​ because:

• The trust had not ensured that ligature points, and risks associated with ligature, were managed safely on The Haldon. There was insufficient details and updates to evidence progress and plans to resolve these.

• Our findings from other key questions demonstrated that governance processes did not always operate effectively at team level and senior leaders in the trust to ensure that performance and risk were well managed.

• There were no clear signage or displayed posters for informal patients to inform that they could leave the ward freely.

However:

• We observed a strong culture of person-centred care being delivered on the ward. Staff treated patients with compassion and kindness and respected their privacy and dignity. Patients were active partners in their care.

• The service proactively supported families and carers, who spoke with gratitude about the support the staff gave them.

• The ward environment was clean, well-maintained and welcoming. Staff assessed and managed risk well.

• Staff minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding.

• Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of patients and in line with national guidance about best practice. Staff engaged in clinical audits to evaluate the quality of care they provided.

• The ward team included the full range of specialists required to meet patients’ needs. Managers ensured that staff received training, including specialist eating disorder training, and supervision. The ward staff worked well together as a multidisciplinary team.

• Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.

• Local managers provided a strong and visible presence within the service. Staff felt respected, supported and valued, and spoke highly of the leadership.

Updated 8 October 2019

Our rating of this service stayed the same. We rated it as good because:

• The community mental health services for people with learning disabilities and autism provided safe care. Clinical premises where patients were seen were safe and clean. The number of patients on the caseload of most of the teams, and of most individual members of staff, was not too high to prevent staff from giving each patient the time they needed. Staff mostly managed waiting lists well to ensure that patients who required urgent care were seen promptly (apart from in the Autism Spectrum Condition service). Staff mostly assessed and managed risk well and followed good practice with respect to safeguarding.
• Staff developed mostly holistic, recovery-oriented care plans informed by a comprehensive assessment and in collaboration with families and carers. They provided a range of treatments that were informed by best-practice guidance and suitable to the needs of the patients. Staff engaged in clinical audit to evaluate the quality of care they provided.
• The teams included or had access to the full range of specialists required to meet the needs of the patients. Managers ensured that these staff received training, supervision and appraisal. Staff worked well together as a multidisciplinary team and with relevant services outside the organisation.
• Staff understood the principles underpinning capacity, competence and consent and managed and recorded decisions relating to these well.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
• The service was easy to access and staff and managers of the Intensive Assessment and Treatment Teams managed waiting lists and caseloads well. The criteria for referral to the service did not exclude patients who would have benefitted from care. Staff assessed and initiated care for patients who required urgent care promptly and those who did not require urgent care did not wait too long to receive help.
• The service was well led and the governance processes mostly ensured that procedures relating to the work of the service ran smoothly.

However:

• The processes in place to ensure high quality care records did not always ensure that patient records had all of the information to ensure high quality care. We reviewed 26 care records across the teams and found that eight were missing elements of care plans or risk management. These were found in six records reviewed in the North and Mid Intensive Assessment and Treatment Team (IATT) and in two records in the Exeter and East IATT.
• Despite trust staff liaising with and working with local commissioning groups, the trust had been unsuccessful in securing the resources to meet the waiting list issues that we identified at the last inspection. Waiting times for the Autistic Spectrum Condition Service were either the same or worse on average since the last inspection and the waiting list had increased.

Updated 15 March 2017

We rated the community based mental health services for older people as good because:

• By the time of the most recent inspection, the trust had addressed the issues that caused us to rate safe and effective as requires improvement following the July 2015 inspection. We have rated each domain as good.

• By the time of the December 2016 inspection, the community based mental health services for older people were meeting Regulations 12 and 17 of the Health and Social Care Act (Regulated Activities) Regulations 2014.

• Staff routinely completed and updated patient risk assessments. They developed and recorded crisis plans with patients. This meant there were plans in place to mitigate risks if patients were in crisis. Staff had a good understanding of safeguarding policies and the procedures to keep people safe from abuse. Teams monitored safeguarding enquiries so they could analyse themes and track responses from other agencies. The service carried out regular environmental risk assessments to monitor and improve the safety of buildings.

• The service had clear policies to support staff when they worked alone. Staff were aware of the lone working policy and procedure. Staff knew how to report incidents and felt able to report concerns.

• Staff knew their patients well. They kept records of patient care and treatment up to date, including any changes in circumstances. Staff routinely carried out mental capacity assessments and supported patients to manage their physical health needs.

• The service worked well with other teams and agencies to enable patients to move between services as their needs changed. Staff communicated promptly and effectively with patients’ GPs.

• Staff treated patients with kindness, dignity and respect. They routinely involved patients and carers in developing their assessments and care plans. The service was responsive to the needs of patients, carers and care homes. Patients told us they could get appointments when they needed them and doctors were accessible to both staff and patients. They said they could easily contact their allocated worker when they needed to speak with them. Patients we spoke to were very positive about the service they received. Individual teams within the service were developing ways to gather patient and carer feedback. The service had a programme to update patient areas such as waiting rooms, to reflect the needs of the patient group.

• Staff had access to regular supervision and there were opportunities for them to develop their skills and career. They were up to date with their mandatory training. Staff had a good understanding of the Mental Health Act and the Mental Capacity Act.

• Local leaders were visible and accessible to staff. They demonstrated that they led their teams well. Staff spoke positively about the support their managers provided to them. Senior managers showed a presence and visible leadership to the service. Staff morale was good in most teams.

• Managers carried out regular team audits, including audits of patient records. They carried out regular service wide audits, including the quality of mental capacity assessments. The service recorded referral and discharge data. They used dashboards to inform staff and managers if they were meeting their key performance indicator targets. This meant they could tell how long people waited to be seen by the teams and if staff carried out patient care and treatment reviews in a timely manner.

However:

• Patients with a diagnosis of dementia were not routinely offered support by the trust outside of normal office hours because they were not commissioned to provide this support. Patients’ crisis plans contained guidance in case they needed support outside of these hours. Family members could also access further support if required from primary care services.

• In some areas of the service, there were 18 week waiting lists for patients to access psychological therapies. Patients had access to a psychology service via the trust's older people directorate.

• Most carers and patients did not know how to make a complaint about the service. Despite this, they told us they were sure they could find out how make a complaint if they needed to.

• Almost all staff told us that, regardless of complexity of need, they did not support older people using the Care Programme Approach. This meant the trust supported people with similar needs in a different way, and this difference was based upon age. Following the inspection, the trust told us they would review this policy.

• Some staff felt senior managers did not listen to the feedback they provided about organisational change and developments within the service.

Updated 15 March 2017

During the most recent inspection, we found the trust had addressed the issues that caused us to rate safe and effective as requires improvement following the July and August 2015 inspection. We have rated each domain as good.

Following the December 2016 inspection, the mental health crisis and health-based places of safety services were meeting Regulations 9 and 12 of the Health and Social Care Act (Regulated Activities) Regulations 2016.

We rated mental health crisis services and health-based places of safety as good overall because:

• At this inspection, we found the trust had made improvements to the quality of the service and care and treatment given to patients. We have rated each domain as good.

• Crisis teams had access to safe and clean environments where people could be seen outside of their homes. Caseloads were managed safely by sufficient numbers of staff who had high completion rates in mandatory training.

• Staff understood people’s risk and assessed this regularly during face to face contact and team handovers. People’s care plans were personalised and recovery focussed. Staff made plans with people to prepare them to better manage their mental health issues, and the risks they presented, after being discharged from the team.

• Staff were knowledgeable in clinical issues such as making referrals to safeguarding teams and incident reporting. Staff attended regular meetings where they openly discussed their practice, shared ideas and learned from each other.

• The service employed a street triage worker who was able to support police when they encountered people in distress in the community. They offered mental health advice and information on people’s current support and contact from mental health services. This helped police make decisions on whether the person needed assessment at a health-based place of safety.

• Crisis teams offered people brief psychological and social support. The service was also improving the way they assessed and monitored people’s physical health. They had made physical health training mandatory and were identifying physical health leads for all teams. The trust had a physical health steering group who were committed to increasing teams’ access to physical health monitoring equipment.

• Crisis teams consisted of skilled staff who were experienced in supporting people in crisis. All staff received a comprehensive induction that prepared them for their roles. They treated people in a caring and professional manner, had a good understanding of people’s needs, spoke with them appropriately and in line with the level of support they required. Carers of people who used the crisis teams told us they felt involved in their care.

• Crisis teams responded to urgent referrals and concerns from people already on their caseload. The service had recently introduced an out of hours phone line so people could access crisis support during the night. Staff who took the calls were able to update people’s electronic care records and record any advice that was given to them. Daily feedback was given to teams so they could offer people appropriate follow up the next day.

• The Torbay and Teignbridge crisis teams were able to refer people to two crisis houses. These services allowed people to be discharged from acute hospital settings early or, alternatively, could be used to avoid people being admitted to hospital. All people were supported by crisis teams whilst using these services, and would receive regular visits and medical reviews by a psychiatrist.

• Staff felt supported by their managers and colleagues and enjoyed their roles. Team managers had full oversight of their team’s daily operation. They attended meetings and shared relevant information with their staff. Psychiatrists and administration staff were fully integrated within the teams.

• Staff had opportunities for career development. We spoke to nurses who had been supported by the trust to complete their non-medical nurse prescribing training and health care assistants who had been supported to complete training to becoming associate practitioners. The trust was committed to improving staff’s clinical skills and provided them ‘your essential practice guide’, a brief guides on improving knowledge in 15 areas of clinical practice.

However:

• Two of the health-based places of safety within the trust had some environmental safety issues and police did not have easy access to them. The same two facilities were overlooked by people using the gardens of inpatient wards. These issues could compromise people’s safety, privacy, dignity and confidentiality. The trust confirmed that both facilities were planned for refurbishments; these would be commenced in April 2017.

• People were not always having their physical health risks assessed and managed whilst being supported in health-based places of safety. Staff in one of the crisis teams were not accurately recording people’s concordance with medicine.

• The systems and documentation used to record and monitor a person’s episode of care, whilst being supported in the health-based place of safety, did not allow staff to record all the information required on the trust’s electronic care record system. This system was also not fully accessible for staff working in the crisis houses. This meant they could read information but were unable to update care records in line with care provided.

• Crisis teams did not have clear guidance from the trust to ensure they were providing a consistent clinical approach. This included teams approach to areas such as, managing people who were not engaging with the service and monitoring key performance indicators. We also found inconsistent approaches to providing staff supervision which had an impact on quality.

• The Exeter crisis team did not have a flexible approach to assessing urgent referrals. We found incidents where they had redirected people to psychiatric liaison services in accident and emergency as they felt they did not have available staff. They did not look at their current workload to see if any appointments could be rearranged.

• The North Devon health-based place of safety was only commissioned to operate between 9am and 5pm, due to it being used, on average, less than once a day. This meant people in the area often had to be transported by the police to Exeter or Torbay whilst in a state of distress.

Updated 16 May 2018

Our rating of this service stayed the same. A summary of our findings about this service appears in the overall summary. We rated it overall as good.

Updated 8 October 2019

Our rating of this service improved. We rated it as outstanding because:

• All staff demonstrated a strong, visible, person-centred culture. Staff were highly motivated and inspired to offer care that was kind, compassionate and promoted patients’ dignity. This was reflected in the way staff interacted with patients, in patients care records, during patient meetings and multidisciplinary meetings.
• Patients were active partners in their care. Staff were fully committed to working in partnership with patients and supported patients to make decisions about their care and their environment for themselves. Feedback from all patients and carers was overwhelmingly positive and all felt staff went the extra mile.
• Patients’ individual preferences and needs were always reflected in how care was delivered. Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
• There were high levels of staff satisfaction across all wards. Staff were proud of the wards as a place to work and spoke highly of the culture. Leaders had an inspiring shared purpose and strived to deliver and motivate staff. There was strong collaboration between staff, patients and leaders.
• Leaders strived for continuous improvement and safe innovation was celebrated. There were clear proactive approaches to seeking out and embedding new and more sustainable models of care.
• The service provided safe care. The ward environments were well equipped, well furnished, fit for purpose and clean. The wards had enough nurses and doctors. Staff assessed and managed risk well. They minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding.
• The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received training, supervision and appraisal. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.
• Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.

However:

• Some wards had environmental safety issues, such as out of date PAT testing, a corroded pipe, long call bell strings and an unfixed oxygen cylinder. The corroded pipe was on the ward’s risk register, being dealt with by estates and managers put plans into place during our inspection to address the other issues.
• Staff had not created care plans for ‘as and when required’ medication, such as Lorazepam
• Staff supervision at Meadow View was not recorded as taking place within the trust’s targets, although staff received weekly peer reflection and monthly staff meetings and staff we spoke with felt they received adequate support and supervision.
• Beds were not always available for older people with mental health needs, which led to some out of area placements. There were 41 out of area placements between 1 March 2018 and 28 February 2019. Adults of working age were occupying beds on three of the wards. On all wards, patients experienced delayed discharges because of a lack of social care beds or beds in a step down facility.

Updated 2 September 2021