Devon Partnership NHS Trust

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.

We carried out a focused inspection of wards for adults of working age and psychiatric intensive care units run by Devon Partnership NHS Trust. This was a focussed inspection, so we did not rate the service during this inspection. The requires improvement rating relates to the rating awarded at the previous inspection.

The wards are registered to provide the following regulated activities;

• Assessment or medical treatment for persons detained under the Mental Health Act 1983.
• Treatment of disease, disorder or injury.
• Diagnostic and screening procedures.

We visited Delderfield ward and Moorland View ward. Delderfield is one of two 16-bedded wards at The Cedars in Exeter. Moorland View is one of two 16-bedded wards at North Devon District Hospital. Both wards are acute inpatient wards that provide assessment, care and treatment for adults with mental health needs.

At the time of our inspection Ocean View, the neighbouring acute adult inpatient ward to Moorland View ward, was being used as a ward for a small number of patients who were being tested for Covid-19 prior to admission as part of the trust’s infection prevention and control strategy.

Ocean View ward was suspended in early June 2019. Ocean View and Moorland View staff teams merged to become one 24-bedded ward to support safe staffing.This was due to difficulties recruiting staff, especially registered nurses. On 30 November, the bed numbers on the merged ward were further reduced to 16 beds following the death of a patient to support safe staffing and manage patient acuity.

We visited Delderfield ward and Moorland View ward due to concerns about patient safety incidents involving ligature incidents and patient deaths. There had been a number of patient safety incidents involving ligature incidents and patient deaths including a patient death on Delderfield ward in March 2020 and two patient deaths on Moorland View ward in September 2019 and November 2019. These were in addition to other serious incidents involving patients self-harming.

On 18 June 2020, following this inspection, we sent the trust a letter of intent under section 31 of the Health and Social Care Act 2008 identifying our serious concerns about the safety of patients on Delderfield ward and requesting the trust submit information to explain how it would make immediate improvement. Section 31 of the Health and Social Care Act 2008 Act is an urgent procedure whereby CQC can vary any condition on a provider's registration in response to serious concerns. A letter of intent sets out our intention to take urgent action if the provider does not assure us that it will make the required improvements urgently. The trust responded to the letter of intent on 22 June 2020 with an action plan. However, we did not feel it set out clearly enough what action would be taken so asked for further assurance. The trust responded on 1 July 2020 setting out further immediate actions it was taking/would take to ensure the safety of patients.

In the Section 31 letter of intent we told the trust we were concerned about the management of environmental risks including ligature risks. The environmental ligature risk assessment shown to us on Delderfield ward was not the latest version as the interim manager told us they did not have access to it. This version had not been updated following recent serious incidents.

We told the trust we were concerned that on Delderfield ward, patient’s observations and intentional rounding were not sufficient to keep patients safe. Staff only randomised formal patient observations if they determined that the patient was at particular risk. This was contrary to the Trust’s engagement and observation policy which stated observations should not be predictable or entirely regular. The predictability of observations exposed patients with self-harming behaviours to a risk of having the opportunity to hurt themselves.

We told the trust we were concerned about the quality, recording, oversight and effectiveness of observations and intentional rounding on Delderfield ward. There was a lack of oversight of observations, despite incidents taking place when observations were missed, or when observation levels had not been sufficient to prevent self-harm.

We asked the trust to tell us how it would improve the quality and oversight of observations and intentional rounding to improve its ongoing assessment and understanding of patients’ well-being, progress and fluctuating risks and in order to appropriately care for patients.

We told the trust we were concerned about a lack of response to audits and a lack of learning from serious incidents. There had been a delay in completing the investigations into recent serious incidents, including the patient deaths. There was evidence of learning from serious incidents on Moorland View ward. However, on Delderfield ward, minimal local learning had taken place following a death in March 2020 and staff said they were waiting for the outcome of the root cause analysis or simply did not know if there was any learning from the death that took place in March.

We had no concerns about the induction process on Moorland View ward where agency staff were monitored during their shift. However, we told the trust we were concerned about the lack of a robust system to ensure agency staff were inducted to the Delderfield ward. An induction checklist was in place, however if staff said they had worked shifts on the ward before, this was not checked to ensure their induction and training was up to date.

We told the trust we were concerned about staff training because staff on both wards told us they had not been formally trained in ligature risk assessment and management. The inspection team reviewed an audit that showed staff felt under skilled in risk assessment. Staff did not receive formal training in patient observations and there was no formal process on Delderfield ward for checking patient observations had been completed.

Delderfield ward had implemented a daily security check on Delderfield ward three weeks prior to the inspection. The daily security check helped raise staff’s awareness of ligature risks on the ward and staff generally found it useful. There was a lack of action to rectify risks because works had been delayed due to the Covid-19 pandemic. In response to the pandemic, in early March, contractors were removed from site by their firm management teams. The Trust advised us it had no involvement in or control over this decision.

In the Trust’s response to our letter on 22 June 2020, the Trust assured us that the Director of Nursing and Professions had visited Delderfield ward to discuss the initial findings and immediate actions with the staff and leadership on the ward. The Trust provided us with an action plan on 22 June 2020 to address our initial findings. The trust provided us with an up to date copy of the ligature risk assessment for Delderfield ward that had been updated in April 2020. However, the environmental ligature risk assessment lacked details of actions taken to mitigate risks so we asked for further assurance. The trust confirmed wards were now ensuring observations were unpredictable for all patients. The trust told us it had briefed staff on the use of the engagement and observation policy, reminding staff to complete observations at variable intervals. The trust told us it had introduced measures to ensure induction was more robust, reviewing the local induction checklist for all agency staff workers on all shifts, regardless of whether or not they had previously worked on the ward. The Trust advised that simulation training in ligature risk assessment and management was being developed for roll out at the end of July 2020.

We wrote to the trust again on 26 June 2020 to request further assurances. We asked for confirmation that the interim manager on Delderfield ward had access to the environmental risk assessment. We asked for more detail about reviewing and auditing of engagement and observation and for confirmation that patients were receiving unpredictable and irregular observations. We noted that Delderfield ward had introduced a weekly audit of engagement and observation. However, this audit was happening daily on Moorland view and we asked the trust to assure us that a robust and regular review of engagement and observation was taking place. We asked the trust to confirm that agency and bank staff on Delderfield ward were being provided with individual supervision and being included in discussions about changes to the observation levels of patients. We asked for further clarification on the risk training being provided to staff and to tell us how it would ensure staff were sufficiently trained, competent and confident in intentional rounding, observation and the assessment and management of patient risk. We asked for more detail about how the trust ensure learning is discussed and disseminated effectively on Delderfield ward. We asked for an update on the expected completion date for the root cause analyses for each of the deaths on Moorland view and Delderfield ward. We told the trust that the risk register they had provided to us for Delderfield ward did not appear to be an active document and that it lacked detail. We asked for assurance of the trust seeking a permanent manager for Delderfield ward. We asked for assurances about the timeframes of the work being conducted by the trust’s ‘preventing and managing ligature events in inpatient settings group’.

The trust wrote to us again on 1 July 2020 and it advised the interim manager had had access to the environmental risk register but had now left the ward. It provided us with its audits of observations for Delderfield ward. These showed that comprehensive observations were taking place in line with trust policy. The trust advised it would be ensuring all staff feel engaged, understand and participate in clinical discussions and decision making. The trust told us it had introduced a three times daily audit of the recording of observations on Delderfield ward. The trust provided Delderfield ward’s updated risk register and it was comprehensive. The trust confirmed that temporary bank and agency staff were being offered supervision. The trust provided confirmation of the governance process for ensuring learning from incidents and audits is discussed and disseminated.

However;

We found positive and proactive leadership on Moorland View and that risks were being managed well.

Staffing levels were safe on both wards. The trust had an active recruitment programme and it was supporting existing staff to undergo nurse training.

Handover were effective on both wards. Handovers were detailed and covered dynamics between patients, physical health risks and patients’ risk.

All patients and carers that we spoke with said staff enabled them to have contact with one another. This was particularly welcomed during the Covid Pandemic lockdown period. Patients, families and carers gave good feedback about staff, describing them as helpful, approachable, supportive, caring, and respectful.

All patients said they were involved in planning about their discharge and families and carers said they were suitably involved in discharge planning.

Patients on both wards talked about enjoying being able to use the gardens which were well maintained, spacious and offered a calming environment

Staff felt the culture on both wards was good and that staff were caring for each other and towards patients. Staff felt respected, supported and valued.

As this was a focussed inspection, specifically to follow up on issues of concern about patient safety, therefore did not rate the service and the rating from the previous inspection still applies.

We conducted an unannounced focused inspection looking at specific areas of the following two key questions:

• Is it safe?
• Is it well led?

During this inspection, the inspection team:

• Visited Delderfield ward and Moorland View ward
• spoke with the ward managers
• spoke with 16 staff including registered nurses, healthcare assistants, support workers and student nurses
• spoke with patients
• spoke with carers
• spoke with stakeholders of the service
• looked at 14 care and treatment records of patients
• attended a handover meeting on Delderfield ward
• looked at a range of policies, procedures and other documents relating to the running of the wards.

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

• We rated the trust as good overall for four of the five key questions, safe, effective, caring and well led. We rated the responsive key question as requires improvement. At this inspection we rated one of the four core services that we inspected as outstanding, one as good, one as requires improvement and one inadequate. In rating the trust we took into account the current outstanding rating in one core service and current good ratings in five core services not inspected this time.
• We rated wards for older people with mental health problems as outstanding because patients were active partners in their care and supported to make decisions for themselves. Consideration of patients’ privacy and dignity was consistently embedded in everything that staff did, including awareness of any specific needs as these were recorded and communicated. They understood the individual needs of patients and supported patients to understand and manage their care, treatment or condition. Patients’ individual preferences and needs were always reflected in how care was delivered. Staff involved patients in care planning and risk assessment and actively sought their feedback on the quality of care provided. Staff sat down with patients and went through their care plan with them. Comprehensive and successful leadership strategies were in place to ensure and sustain delivery and to develop the desired culture. Incidents were low due to a deeply embedded caring culture within the wards. There was high levels of staff satisfaction across the service. Continuous improvement and safe innovation was encouraged and celebrated. Constructive challenge from patients and carers was welcomed and documented in the patient meetings and minutes. There was a strong focus on improving the quality of care and patients’ experiences.
• All clinical areas and premises where patients received care were clean, well equipped and maintained.
• Staff minimised the use of restrictive practices and followed best practice when de-escalating and managing challenging behaviours. Beech Unit had won an award for their roll out of the ‘four steps to safety’ programme. Since implementation, their violent and aggressive incidents had halved.
• The trust managed incidents well and staff understood how to report them appropriately. Incidents were investigated and lessons learned were shared.
• Staff treated patients with compassion, respect and kindness. The privacy and dignity of patients was maintained at all times. Staff were familiar with patients and understood their individual needs. Patients were supported by staff to understand and manage their care and treatment. Families and carers of patients were involved in their care appropriately.
• Staff supported patients to make decisions about their care for themselves. Staff understood the Mental Capacity Act 2005. Staff worked within the trust’s policy and clearly recorded and assessed capacity for patients who may have impaired mental capacity. Staff involved and worked with the patient’s relatives and carers to ensure best interest decisions were made when appropriate.
• Concerns and complaints were treated seriously by the trust. Complaints were investigated and lessons learned were shared with all staff.
• The trust had a leadership team with an appropriate range of skills, knowledge and experience to deliver mental health services. The board was well established and stable.
• The trust was financially stable and had expertise among executives and non-executive directors relating to finance. The trust had a clear understanding and oversight of their financial position. This was regularly discussed at board meetings. The trust had a proven track record of achieving financial targets.
• There were a range of mechanisms that provided assurance from service level to board level for most services. Directorate governance meetings were held regularly and considered service line performance.
• The trust engaged well with patients, staff, equality groups, the public and local organisations. These relationships were used to plan and manage appropriate services. The trust had further embedded the ‘Together’ engagement programme since the last inspection. The programme brought people with lived experience, including carers, to develop and co-design services. The philosophy of Together was evident in all areas of the trust and used for all engagement activity. The trust also had a number of equality, diversity and inclusion groups which met regularly.

• The trust used quality improvement methodology. Over 900 staff had been trained in quality improvement. Staff were committed to continually improving services and innovation was encouraged by leaders. For example, the ‘four steps to safety’ programme had led to a reduction in violence and aggression on inpatient wards and also a 50% reduction in seclusion.

• The leadership team and staff throughout the trust were open and transparent. The trust had a clear set of vision and values that were at the heart of staff who worked for the trust. We saw the trust’s values embedded in the services we inspected.

However:

• We had serious concerns about the community-based mental health services for adults of working age. The trust did not have clear oversight of the large number of people on the waiting list. All the teams we inspected were not safely monitoring patients on the waiting list or responding to changing and increased levels of risk. Patients on the waiting list were not contacted by the teams in line with the trust’s protocol. Patients were waiting long periods of time to access services. Some teams were unable to quickly respond to high-risk or urgently referred patients, who should have been allocated within a week. Some high-risk and urgent patients were waiting up to a year to be allocated and receive treatment. Concerns by staff about the level of risk in the service had not been responded to appropriately by the trust. As a result of the significant concerns identified we wrote to the trust to seek immediate assurances about the safety of the service. We did this under Section 31 of the Health and Social Care Act 2008 to notify the trust of the serious concerns that had been identified during the inspection. The Section 31 powers offer a provider the opportunity to put forward documentary evidence to provide assurance that identified risks have been removed or are to be immediately removed. We received immediate assurances from the trust and work was undertaken to review the waiting lists and assess the risk of those people on the waiting lists.
• A substantial number of staff that we spoke with in the community mental health teams did not feel listened to by the trust. Staff morale within the service was low and staff reported what they perceived to be a bullying and blame culture. The long waiting lists was causing pressure and stress on staff within the team.

• Staffing numbers on the acute wards for adults of working age and in the community-based mental health teams for adults of working age were insufficient. In the community mental health teams staff caseloads were high and the number of referrals exceeded the number of discharges. This was causing long waiting times for patients to be allocated and receive treatment. On two of the acute wards nursing vacancies meant newly qualified nurses were working shifts without an experienced registered nurse.
• The trust was unable to provide enough beds to ensure patients received treatment within trust area beds. The number of patients treated in out of area beds had increased since our previous inspection. Between March 2018 and February 2019 379 patients had been treated in out of area beds. During the previous inspection there had been 217 out of area placements. Some adults of working age were being cared for on the wards for older people with mental health problems due to bed shortages. This was impacting on both services. Beds were not always available on the acute wards for adults of working age and patients who had been on leave did not always have a bed to return to. On the wards for older people the number of restraints had increased. This was related to adults of working age who had been admitted onto the wards. The trust had opened a new ward in January 2019 to increase bed numbers available and were also in the process of designing a new ward on the Torbay site to open in 2021.

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.

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.

Following this inspection, we served a letter of intent to the trust. We did this under Section 31 of the Health and Social Care Act 2008 to notify the trust of the serious concerns that had been identified during the inspection.  The letter of intent detailed that we would take enforcement action if the trust did not take immediate action to address concerns raised. The Section 31 powers offer a provider the opportunity to put forward documentary evidence to provide assurance that identified risks have been removed or are to be immediately removed. We received immediate assurances from the trust and work was undertaken to review the waiting lists and assess the risk of those people on the waiting lists.The trust sent the commission an action plan which detailed what steps they had and will continue to take to ensure it delivered safe services. We therefore took no further action and will continue to monitor and engage with the trust closely to ensure on-going improvements are made.

Our rating of this service went down. We rated it as inadequate because:

• None of the teams we inspected were safely monitoring patients on waiting lists to detect and respond to increases in level of risk. Staff were not always contacting patients on waiting lists in line with the trust’s protocol. Staff did not update risk assessments of patients on waiting lists following their initial assessment. Patients were not always prioritised in line with trust policy. For example, patients who disclosed they had become pregnant while on the waiting list did not become urgent referrals and move up the waiting list. Some teams were unable to monitor and quickly respond to high-risk or urgently referred patients, who should be allocated within a week. Some high-risk and urgent patients were waiting between 28 days and a year to be allocated and receive treatment.
• The service was unable to provide treatment to all patients within the 18-week referral to treatment target time. Patients who were referred as urgent were not always being assessed and allocated within one week. This was raised as a concern at the previous inspection and during this inspection we found that patients were waiting significantly longer to access the service.
• Patients were not able to access psychological therapies in a timely manner. Patients would only be referred to the psychology team if they had been allocated a care co-ordinator. Some teams had identified that approximately 50% of patients on the waiting list would benefit from psychological intervention.
• Except for the Exeter community mental health teams, staff were not always assessing and monitoring the physical health of patients in line with best practice recommended by the National Institute for Health and Care Excellence. This was raised as a concern at the previous inspection and despite progress being made, the majority of teams were not monitoring and assessing patients’ physical health appropriately.
• Staff establishment figures were insufficient to allow adequate caseload management. Managers could not recruit above established levels and had previously been asked to reduce staffing numbers due to a change in budget. Staff were working at full capacity, and many were stressed and at the point of burn-out. Staff described a ‘flow and capacity issue’ as the number of referrals received by the service out-weighed the number of clients being discharged. Some teams were being impacted by staff absences such as those on long-term sick or on maternity leave. One team did not have a consultant psychiatrist and this role was being covered by other consultant psychiatrists in the locality, putting additional pressure on the staff to ensure patients had their medical needs met. In one of the Exeter teams there had not been a substantive consultant psychiatrist for over two years and there had not been a consistent locum in place.

• Staff at all levels described an unsupportive, blame culture from the trust board. Of the staff we spoke to, eight described a negative culture within the trust. Staff were afraid to make mistake during the inspection as they feared being reprimanded by the trust. Some staff felt valued by the trust. However, most felt that their service had been neglected, and that funding and focus was on more specialist services. Staff felt this pulled resources from the community mental health teams. There were areas of good morale in the teams, but this was variable. Of the staff we spoke to, 18 described being stressed, under pressure and close to burn out. This was particularly apparent in the teams in South and Central Torbay, who had low levels of morale.

However:

• Managers made sure that staff had a range of skills needed to provide high quality care. They supported staff with appraisals, supervision and opportunities to update and further develop their skills. Staff in the Torbay North team had received ‘Open Dialogue’ training and were identifying patients who would benefit from this specific intervention.
• Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse, and they knew how to apply it.
• A community mental health team had been set up at the University of Exeter to provide students with quick access to mental health services. Since opening in January 2019, the service had reduced the attendance of students to the local emergency department presenting with mental health distress by 60%.
• Carers told us that they were kept informed about their loved one and that information was clear and easy to understand. Carers said they were involved in decision-making and invited to meetings when appropriate. We were told that staff were non-judgemental and that they were confident their loved ones received the right support.

Our rating of this service went down. We rated it as requires improvement because:

• Managers on Moorland View had not risk assessed the ward environment to ensure all areas of the ward could be observed. Staff on Moorland View, Haytor ward and Delderfield ward were unaware of environment risks on the wards, such as blind spots, and were not acting to mitigate these risks. Moorland View bedrooms were not well maintained and there was broken equipment in the accessible bedroom. There was mould in the communal bathrooms on Coombehaven, Haytor and Moorland View wards.
• Staff on all the acute wards did not always develop robust risk management plans in response to identified needs and changing risks. Risk management plans were brief and did not address individual risks with interventions. Staff did not consistently review risk assessments and management plans in response to incidents and episodes of restraint or seclusion. Staff on Coombehaven ward did not ensure a doctor reviewed seclusion after one hour in line with the trust policy and were not documenting reasons for this not taking place.
• On the acute wards, staff did not ensure that care plans reflected patients’ preferences and these were not always person-centred. Care plans on Coombehaven and Delderfield ward did not consistently meet patients' assessed needs and were not person-centred.
• Moorland View and Coombehaven ward teams had high vacancy rates for registered nurses. Managers on Haytor ward and The Junipers had not ensured that newly qualified nurses always worked with a second nurse and an experienced nurse. Clinical psychologists were unable to provide a full range of psychological interventions due to having to work on more than one ward. Managers had not ensured that staff received regular supervision and timely appraisals.
• The trust was unable to provide enough beds to ensure patients received treatment within trust area beds. Between March 2018 and February 2019, 379 patients were placed in out of area beds. Some patients were admitted to the older adults ward to ensure they remained in their local area. Patients did not always have a bed available when they returned from leave and staff were not supporting patients to pack their belongings before leave. If patients returned from leave and their bed had been taken, a bed would be sought on another ward or out of area.
• Managers on the acute wards had not ensured that patients’ risk and ward environmental risks were adequately assessed and managed. The trust did not have oversight of the impact of high vacancies and bed occupancy on the number of patients whose leave had been cancelled due to staffing and patients whose beds were no longer available to them when they returned from leave. Managers were aware that supervision and appraisal compliance was below 62% for all the wards and the action plans to address this had not yet improved compliance. Clinical audits of care records were insufficient to ensure patients were receiving comprehensive and person-centred care.

However:

• The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare. The service had reduced its number of delayed discharges and employed discharge facilitators on all the wards to support patients with accommodation needs.
• Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it.
• 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.

Our rating of this service went down. A summary of our findings about this service appears in the overall summary. We rated it overall as requires improvement.

Our rating of this service improved. A summary of our findings about this service appears in the overall summary. We rated it overall as outstanding.

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.

Our overall 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.

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.

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

• We rated safe, effective, caring, responsive and well-led as good. Our rating for the trust took into account the previous ratings of services not inspected this time.

• We rated forensic inpatients/secure services as outstanding overall.

• The trust’s senior leadership team had the skills, knowledge, experience and integrity necessary for successfully overseeing a large, complex organisation.

• The senior team was committed and passionate. They had developed a positive ethos of engagement with patients called ‘Together’ (working together in everything we do) and were embedding a culture of quality improvement which was showing improvements in service delivery.

• We saw evidence of some excellent leadership at all levels across the trust with many dedicated, compassionate staff who were striving to deliver the very best care for patients.

• Staff and stakeholders told us there had been a change in the culture of the trust over the last 18 months to one that is very open and honest. The trust was seen as a good partner to work with and partners said that the trust delivered high standards of care.

• Patients and carers were, on the whole, extremely positive about the care they received and believed the trust was a good place to receive care

• The trust had set an aim to become a ‘centre of excellence’. It was transforming its services to meet Devon’s needs in the longer term as well as working to improve current services. One of many examples of transforming services was that of the new the mother and baby unit; a purpose built unit.

• The trust had developed a financially stable position and this was able to facilitate service development, including some capital investments to ensure progress on the onwards journey to delivering it vision and strategy.

  However:

• We changed the rating for one service, community mental health services, from good to requires improvement due some poor practices in medicines management, a lack of physical health care monitoring and long waiting times for treatment (over a quarter of patients waited longer than 18 weeks). Shortages of staff had led to large caseloads and an inability to always respond to patients that phoned into the duty telephone service for support.

When aggregating ratings, our inspection teams follow a set of principles to ensure consistent decisions. The principles will normally apply but will be balanced by inspection teams using their discretion and professional judgement in the light of all of the available evidence.

After the most recent inspection in December 2016, we have changed the overall rating for the trust from requires improvement to good because:

• In July 2015, we rated four of the nine core services as good. The intelligence we received, before the December 2016 inspection, suggested they had maintained their quality.
• In response to the December 2016 inspection findings, we have changed the ratings of five core services from requires improvement to good. These core services are:​

- Acute wards for adults of working age

- Community-based mental health services for older people

- Mental health crisis services and health-based places of safety

- Wards for older people with mental health problems

- Wards for people with learning disabilities or autism.

• The trust acted to meet the requirement notices we issued after our inspection in July 2015.
• Incidents across the trust had a detailed investigation and action plan developed. The trust had a quality improvement academy that worked with individuals and teams across the trust. They had a central ‘learning from experience’ group which included representatives from all service areas and corporate teams; this considered all areas of learning including incidents.
• The percentage of staff who were trained in safeguarding across the trust was over 90%. Staff knew how to make safeguarding alerts. Safeguarding alerts were recorded as incidents on the risk management system. There were opportunities to discuss safeguarding concerns in ward rounds and other staff meetings although it was not a standing agenda item.
• The trust had launched the four steps programme as a project in partnership with another trust. This aimed to reduce the prevalence of violence and aggression on wards. It supported staff and patients working together to deliver evidence based interventions that reduce levels of violence.
• The trust had prescribing guidelines and psychiatrists referred to these and to National Institute for Health and Care Excellence guidance. For example, we found that this guidance in prescribing medicines for psychosis, depression, schizophrenia and bipolar affective disorder was being followed.
• In addition to mandatory training, the trust offered further training in cognitive behavioural therapy, mindfulness, motivational interviewing, mentorship, counselling skills and solution focused brief therapy. Healthcare assistants took the care certificate training to ensure they acquired the knowledge and skills required for their work.
• We observed staff interacting with patients in a gentle and respectful manner across the trust. Staff prioritised listening to patients, even when they were busy. Staff were genuinely interested in patients and to have a good rapport with them. There was a caring and calm atmosphere on in-patient wards.
• Trust board members interviewed were clear about the trust’s vision and strategy. Senior clinicians were clear about their role and the trusts direction. The vision and values were on display in the trust and were available on the intranet. The majority of staff knew and understood the values of the trust.
• The executive team carried out regular walkabouts and each year were assigned a directorate which meant that they visited all locations and most services and sent reports and any actions of their visits back to teams and reported this activity to the board.
• The trust’s mortality diagnostic and mortality group provided a forum for senior clinicians to review case studies and improve clinical practice within the trust.
• All of the trust’s acute wards for adults of working age and psychiatric intensive care units were in the Royal College of psychiatrists - accreditation for inpatient mental health Service (AIMS) schemes.

However:

• We have again rated acute wards for adults of working age and psychiatric intensive care units as requires improvement for the safe domain. We were concerned about the environmental risks on these wards. Some ligature risks which had been rated as high risk by the trust had not yet been addressed although there were clear plans to do so.
• Staff vacancies continued to be a pressure on older people’s inpatient services, particularly at Meadow View in North Devon and Belvedere the dementia unit. Nursing posts remained difficult to fill. Meadow View still had a vacant consultant post, covered by a locum.
• In some areas of the service, there were waiting lists for patients to access psychological therapies.
• In the older person community servcies almost all staff told us that, regardless of complexity of need, they did not support older people under the Care Programme Approach (CPA). The trust told us they were reviewing the CPA policy to include older people’s services.
• Refurbishment of the seclusion room facilities on the inpatient ward for people with learning disabilities and autism had not yet commenced, although the trust had not needed to use this facility for over 15 months. Funding and building work plans were in place and we were informed that this would start in February 2017.
• The trust had not ensured that the actions from their delivery plan developed in response to the Green Light self-assessment audit were fully embedded and followed up.

The full report of the inspection carried out in July/August 2015 can be found here at:

• http://www.cqc.org.uk/sites/default/files/new_reports/AAAD7774.pdf

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.

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.

• 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 2015 inspection. We have rated each domain as good.
• Following the December 2016 inspection, the wards for older people with mental health were meeting Regulations 11, 12 and 17 of the Health and Social Care Act (Regulated Activities) Regulations 2014.

We have rated older people with mental health problems as good overall because:

• The provider had met all the requirements made following the previous inspection in July 2015. Seclusion was safely managed. Ligature cutters and medical equipment were accessible. Monitoring and checks of medical equipment and alarms were regularly checked to ensure they were fit for purpose. Systems were working to ensure that alarm and nurse call systems were regularly checked and charged. The treatment escalation plans were individually assessed and were completed in full.

• The provider had met or partially met all the recommendations following the previous inspection in July 2015. The trust were meeting same sex accommodation guidelines. The trust had ensured that information on white boards in ward offices were not visible to patients or ward visitors. Rapid tranquillisation was only prescribed when it was indicated and not written up in blanket way. Availability of carers support was clear on all wards. Access to independent mental capacity advocates was clear. Community services were individually assessed so that if the needs of a person under 65 suited the older person’s community team then this could usually take place if appropriate. Help for visiting carers and relatives who did not live locally was supported on an individual basis by the ward managers.

• The service had implemented the four steps to safety programme on two of the four wards, which was an observation and assessment predictor tool where patients are observed and supported over a 24 hour period. Rougemont and Beech were in the process of rolling this out at the time of our inspection which staff felt had had a positive effect on the quality of care and managing conflict and aggression. All wards we visited appeared calm and well managed despite the pressure on beds and admissions.

• Most ward teams worked well, in particular Beech Unit where the team ward manager and consultant worked particularly well together. This was the only inpatient ward in the trust that had no ward staff vacancies, which reflected the success of the Beech Unit team.

• The trust was recruiting creatively where they had been unable to fill vacant nursing posts. For example on Belvedere they had recruited an occupational therapist to the ward team.

• Some staff vacancies had been filled, for example Belvedere ward and Rougemont ward had a manager in place for both wards.

However;

• Beds were not always available for patients on return from leave although this being managed by the trust. Maintenance at Torbay was not always timely, although this was actively managed on beech ward at a local level and through a multi-agency action plan at a senior level and had improved.

• Staff vacancies continued to be a pressure on older people’s inpatient services, particularly at Meadow View in North Devon and Belvedere the dementia unit. Nursing posts remained difficult to fill. Meadow View still had a vacant consultant post, covered by a long term locum. The vacant posts were affecting the wellbeing of the team.

• Although most staff attended regular team and supervision meetings, some staff had not had recent clinical supervision.

• Staff on Meadow View were not always clear as to when to make a safeguarding alert. For example, safeguarding alerts where not always made when a patient had capacity. We asked the ward and the trust safeguarding team to review this and make a safeguarding alert for a patient. The trust confirmed that they had done this and reviewed their system on Meadow View to ensure that they made alerts when required and not depending on the capacity of the potential victim.

• Risk assessments were variable in quality.

We rated wards for people with learning disabilities or autism 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.

• Staff completed physical healthcare checks on patients and these were recorded clearly and consistently so that staff could quickly identify any changes or concerns and take the required action. The service used a standardised system called Modified Early Warning System.

• Patients had a comprehensive assessment in place that was individualised and person-centred with a focus on patient goals and recovery. Evidenced based treatment was used to support the delivery of high quality care.

• Care plans were personalised, holistic and recovery oriented. Patients had a copy of their care plans in an easy to read format.

• Prescribing of medicines followed good practice guidelines. Pharmacists supported staff and ensured medicines were stored and administered correctly. The service participated in medicine audits.

• Staff treated patients with respect and kindness. Staff involved carers and families in patients’ care with patients’ permission or if they lacked capacity in their best interests. The innovative user engagement approaches implemented by the service ensured that patients and their families had a say in how the service was run.

• The service had a robust multidisciplinary team who worked well together and were fully involved in patient’s care.

• Patients experienced care and treatment that was compassionate, sensitive and person-centred. Staff morale was extremely high and the wards supported each other. We found the wards to be well-led and there was clear leadership at a local level. The ward managers were highly visible on the wards during the day and were accessible to staff and patients.

• There were systems in place to monitor and improve the performance of the service. These included patients’ care pathway, safeguarding, incidents, and complaints.

• There was learning and development across the service from untoward incidents and complaints.

However:

• Trust wide food menus were not available in an easy to read format to support the needs of the patients at the service. Patients also did not h ave a way of summoning staff for assistance when in their bedrooms if they required urgent help. Not all patients had advanced decisions in place when required.

• Refurbishment of the seclusion room facilities had not yet commenced. The trust told us that funding and building work plans were in place and we were informed that this would start in January 2017. Although, information provided by the trust showed that the seclusion suite had not been used for approximately 15 months prior to the inspection. 

• The service was not meeting the trust's own target for mandatory training. Not all staff had access to training courses such as basic life support or immediate life support. Staff were also not receiving  appropriate access to supervision and appraisals.

• In response to the Green Light self-assessment audit, the trust had developed a delivery plan but actions from the plan were not fully embedded into the service or followed up.

During the most recent inspection, we found that the trust had addressed some of the issues that caused us to rate safe and effective as requirement following the July and August 2015 inspection. We have changed the rating of effective to good. However, safe remains requires improvement.

Following the December 2016 inspection, the acute wards for adults of working age were found to be breaching Regulations 12 and 13 of the Health and Social Care Act (Regulated Activities) Regulations 2014.

We have rated Devon Partnership NHS Trust 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.
• Wards were cleaned regularly and there was good infection control.
• Patients’ physical health needs were assessed and monitored and when they needed treatment off the ward this was facilitated by staff.
• Prescribing of medicines followed good practice guidelines. Pharmacists ensured that medicines were stored and administered correctly. Patients were provided with written information about their medicines and were invited to discuss their medicine with a pharmacist.
• Staff treated patients with respect and kindness. Staff involved carers and families in patients’ care with patients’ permission. Patients received additional support from the trust’s chaplaincy service and from independent mental health advocates.
• Systems were in place to manage the demand on bed capacity. Wards increased their staffing numbers to accommodate higher patient numbers. Ward managers prioritised the safety of all patients when admitting new patients.
• Despite difficulties in recruiting nurses, ward managers ensured there was always an experienced and qualified nurse on the ward.
• Staff had good morale overall. Staff found their managers supportive and they were appraised annually and received appropriate supervision.
• There were systems in place to monitor and improve the performance of the service. These included ensuring assessment and treatment stages of patients’ care pathway were completed and documented effectively.
• There was learning and development across the service from untoward incidents and complaints.
• Care records showed patients were receiving personalised care.
• Patients had access to evidence based group treatments.

However, our rating of the safe domain remains ‘requires improvement’ because:

• Although the trust had undertaken work that removed most of the blind spots on the wards, one had not been removed or mitigated. Despite works to reduce ligature points there remained some potential ligature points that could reasonably have been remedied. Some ligature risks which had been rated as high risk had not yet been addressed although there were clear plans to do so.
• Patients and staff told us they that when they were busy could not always escort patients on leave and they did not record and monitor when leave was cancelled.

We rated Devon Partnership NHS Trust community-based services for older people as requires improvement because:

• The quality of people’s care records varied in detail and quality in all the services we visited. Care plans were not always person-centred and they lacked detail required to demonstrate an understanding of the individual's circumstances and needs. Care plans did not always reflect changes in people's circumstances, and were not always clearly linked to assessment of needs and identified risks. This meant up to date information was not easily available or accessible to staff.

• Most care records we looked at did not contain clear, detailed crisis plans. Carers and patients we spoke with did not know how to contact someone in the event of a crisis. However, the trust undertook a review of a sample of records following inspection and stated that while the RIO electronic notes may not have contained a crisis plan, contingency plans were included in letters to the GP and the patient. The letters included contact details.

• Access to some sites was difficult. Although they were based within large general hospitals, signage in the older person's community mental health team part was poor and some of the other buildings had poor décor. Some furniture was not appropriate for older people, for example, low chairs, and some interview rooms were bare and poorly soundproofed.

• Environmental risk assessments had not been undertaken in community locations, although three of the sites we visited were based within large general hospitals. This meant there was no overview of the safety and suitability of the buildings. Most rooms did not have easily accessible alarms; staff viewed the client group as low risk of violence and aggression.

• Mental capacity assessments were not recorded in 18 out of 37 care records we reviewed, and of these at least six records reflected that people may not have capacity. 34 out of 37 care records had not clearly documented if the person had consented to information being shared, or with whom.

• We reviewed the referral quality assurance data provided by the trust. The data to monitor compliance with referral and response times did not reflect what teams were reportedly doing. The trust advised that the data they provided did not reflect team practice, due to the central referral system. From additional information requested from the trust, it was not clear how the directorate monitored performance with referrals, in order to ensure capacity within the service and that response times were being met.However, the trust advised that they provided waiting times data to their commissioners.

• Staff were concerned how the new hub and spoke model would affect their roles and the client group. For example, one hub in Torquay would involve a large geographical spread involving a large amount of travel time for some people, who may have cognitive impairment or mobility issues. Staff were not clear how people who used the service and their carers had been involved with the consultation for this model of care. The trust advised that they were planning to deliver a workshop, with the trust`s ‘lived experience' advisory panel and ‘be involved Devon’. The workshop would be aimed at people and carers that have used trust services, with regard to the SMART recovery programme, clinical hubs and single point of access.

• Lone working procedures were not consistent across the teams.

However:

• Staffing information provided by the trust, and observations during inspection, did not reflect any significant gaps in staffing levels. The training records showed that staff were up to date with mandatory training across the teams.

• The teams discussed clinical risks at weekly multidisciplinary meetings. Overall, risks were clearly documented and up to date in care records. Staff knew what kind of incidents to report and the procedures to report. Staff understood local safeguarding procedures, and what their responsibilities were.

• The care provided was in line with evidence based national guidelines, for example the Department of Health National Dementia Strategy. The service had developed clear care pathways. The teams had a wide range of experienced and qualified staff.

• People we spoke with were happy with the care they received from the service. People said that staff were polite, caring and respectful and felt staff were interested in their well-being. People said they were always treated with dignity and compassion. Staff had a good understanding of people’s individual needs and social support systems.

• Each team had capacity to undertake routine and urgent referrals. Patients, carers and other professionals we spoke with, confirmed that calls were returned in a timely manner. Staff confirmed that they were able to respond effectively if they needed additional visits or contacts.

• Staff knew the organisation's vision and values. Overall, most staff felt that there had been more positive engagement from the executive team in the last 18 months. Staff, across all teams, spoke positively about the support they received from their colleagues. The level of support provided by team managers varied, although overall we found evidence of good local leadership.

• The teams all held weekly meetings and managers attended the monthly directorate meetings, where a range of quality and safety issues were discussed. Each team had a local risk register and information was shared with the senior team at the monthly directorate meeting. Managers had access to the trust 'Orbit' management system and 'Develop' training system, which enabled them to monitor individual team performance.

• Administration systems supported clinical staff effectively.

We rated Devon Partnership NHS Trust forensic inpatient/secure wards as good because:

• Care and treatment was delivered in a person-centred, kind, respectful and considerate way.
• Patients and their carers told us that staff treated them with kindness, dignity and respect.
• Patients and their carers were involved as partners in care planning.
• Patients and families told us they were satisfied with the care provided.
• All but two of the 29 patients we asked, said they felt safe on the wards.
• Care Programme Approach and patient clinical ward reviews were routinely carried out in a timely manner.
• Patients had suitable care plans and risk assessments, which were regularly updated and reviewed.
• There was a strong culture of staff managing complex patient behaviours effectively, using restraint and medication only when needed.
• Staff had a good understanding of the Mental Health Act. They had access to support when they needed it and the legal paperwork was completed correctly, recorded effectively and stored appropriately.
• The electronic records systems were effective in supporting staff to deliver care.
• The onsite pharmacy team were accessible to ward staff and provided both monitoring and support with medication management.
• The ward environments promoted dignity and well-being for patients and there was good access to outdoor space.
• Patients had routine and regular contact with a range of onsite and local community health professionals to promote their physical health and well-being.
• Different professions worked effectively together to assess the needs of patients and to support the admission and discharge process.
• There was an active occupational therapy and sports activity team that developed individual plans and therapeutic activities with patients.
• Staff showed a clear understanding of the Mental Capacity Act, including Deprivation of Liberty Safeguards (DoLS) even though they had no reason to use DoLS.
• Staff told us they felt valued and supported by the trust and felt confident they could report their concerns without fear of reprisal.
• There was suitable training available for staff to enable them to keep up to date with their clinical skills and to develop them further. Clinical staff had access to leadership training and there were opportunities for career development.
• There were robust systems to record incidents of harm or risk of harm and learning from incidents was routinely shared among staff.
• Morale among the staff we spoke to was good; they enjoyed their jobs and were clear about their roles and responsibilities.
• Local leaders were visible and available to support staff.
• Robust governance was in place, including audits of service quality and clinical practice.
• Senior managers had good oversight of the service and change was being managed effectively.

However, we also found that:

• Some patients could not access psychological therapies in a timely manner but the hospital had acknowledged this and had recently recruited more psychologists to fill vacant posts.
• Patients in seclusion had access to toilet and washing facilities but these were located outside of the room, requiring staff to facilitate access. Patients in seclusion at the Dewnans centre had to share the facilities with patients in long-term segregation. The seclusion room at Avon house had no intercom, no air conditioning and there was limited natural light from a small window.

We rated long stay/rehabilitation mental health wards for working age adults as good because:

• The ward was clean, hygienic, with necessary equipment maintained and checked.

• There was sufficient staffing to meet patient need. Patient leave was never cancelled because of lack of staff.

• The care plans were informative and up to date. Staff showed a good understanding of patients’ needs and a commitment to meeting them.

• There was good physical health care, with prompt and regular health checks, and good medication practice, with medicines being stored, administered and recorded safely.

• There was a good mix of health professionals who worked together in the best interests of patients.

• Incidents were reported and learned from, with de-briefings and improvements in practice as necessary.

• Rating scales were used to determine individual needs and outcomes, enabling the service to chart the progress of individual patients.

• Mental Health Act and mental capacity documentation was in good order, showing that the organisation was meeting its obligations to patients under the Mental Health Act and the Mental Capacity Act.

• Staff were respectful and responded appropriately to the needs of patients. Staff showed a good understanding of the individual needs of patients.

• The service responded to patient need by taking people from more secure environments and supporting them to move to more independent settings within reasonable time limits.

• Within the confines of a hospital ‘institutional’ environment, the service provided a pleasant outdoor area and a variety of rooms for activities.

• The ward had been accredited as an ‘excellent’ inpatient rehabilitation unit by accreditation for inpatient mental health services the previous year.

However:

• Patients’ views on their treatment were not always recorded in their care plans.

• Morale amongst the staff team was mixed. However, this did not affect staff’s professionalism in responding to patient need, as shown by team responding to patients’ need and planning to meet needs during team meeting discussion.

We rated wards for older people with mental health problems as requires improvement because:

• Ligatures cutters were not accessible on all wards.
• Wards were not fully complying with same sex accommodation guidance to ensure that there was gender separation and privacy.
• The extra care area was used for seclusion and segregation on Rougemont and Belvedere wards. This did not fully comply with seclusion and segregation Mental Health Act (MHA) code of practice.
• Extra care facilities at Franklyn hospital were not included in the designated areas for seclusion, identified in the seclusion and segregation policy.
• Seclusion facilities were not safely accessible for Beech ward patients.
• Medical equipment was not always regularly checked in accordance with trust policy and guidelines.
• There were times when patient’s personal information displayed on white boards was not fully protected.
• Treatment escalation plans (TEPs) were not fully completed.
• Leave authorisation forms for detained patients did not always clearly define the conditions of leave and did not contain specific leave risk assessments.
• At least two staff on each ward did not demonstrate a clear understanding of the Mental Capacity Act (MCA), although additional training for staff was in place at the time of our visit.
• Independent mental health advocates (IMHA) arrangements were not in place for some patients and independent mental capacity advocate (IMCA) arrangements were not always clear.
• There were pressures on beds caused by high demand and delayed discharges. The pressure on beds meant that beds were not always available for patients on return from leave.

However:

• All the wards were clean and bright and well maintained with pleasant courtyards and gardens, with most wards providing dedicated areas to support treatment, care and activity.
• There was a dementia friendly environment including sensory garden and portable sensory equipment in use on Belvedere ward.
• The trust had highlighted staffing as a risk in older people’s services and were actively monitoring staffing and recruiting new staff. Wards were mainly staffed as per the agreed establishment and the number of estimated nurses matched the actual numbers that were working.
• The trust had highlighted delayed discharges as a risk and was actively monitoring. There was a discharge coordinator and a part time social worker on the ward with the most delays in discharge.
• The trust used NHS professionals as temporary staffing whenever possible as they were familiar with the wards and included in staff training.
• Risk assessments, physical and mental health monitoring and investigations followed a clear system and were up to date. Assessment of needs and planning of care was comprehensive.
• All the staff we spoke with were caring and committed.
• Patients and carers told us that staff were respectful, responsive and kind.
• There was participation in ward community meetings and patients were able to get involved in decisions about their service and give feedback.
• There was a commitment to improving the quality of food and staff worked with the catering teams and dieticians to ensure this.
• Staff were regularly appraised and supervised and were up to date with mandatory training.
• The senior management team were visible and approachable and staff were familiar with the trust’s visions and values.
• There was evidence of good practice for example, the older person’s team had been shortlisted for a nursing times award for their successful falls reduction programme.

We rated community mental health services for people with learning disabilities and/or autism as good because:

• There were safe levels of staffing. Staff turnover was low and vacancies in the teams were well managed. With the exception of one long term administrative vacancy.
• People using the service were supported in environments which were clean and fitted with safety alarms. Accessible information about relevant services was clearly displayed on the walls.
• Caseloads were low and people could access a psychiatrist on the same day.
• Within the past 12 months, teams averaged over 90% compliance with mandatory training including safeguarding adults, basic life support, infection control and fire training.
• Care and treatment was delivered in a person-centred, kind, respectful and considerate way.
• People who use services and their carers said that staff treated them with kindness, dignity and respect.
• Staff completed detailed assessments and care plans which were up to date and person centred.
• Staff followed NICE guidelines and people using the service used a wide range of psychological therapies. Primary care liaison nurses prioritised physical health checks and used imaginative approaches to support people to access primary health care services.
• Teams worked well with each other and shared best practice via regular multidisciplinary meetings.
• Feedback from people using the service, their families and external services was positive about staff attitudes and involving them in their own care planning.
• Locations were accessible for people who required disabled access.
• Staff spoke highly of their managers and teams knew who their senior management team were.
• Staff were confident about raising any concerns and understood the procedures around whistleblowing.

However:

• A long term vacancy for a full time administrative post in Exeter and east intensive assessment and treatment team (IATT) placed additional pressure on the clinical staff. Responding to phone calls and addressing paperwork put extra strain on the team.
• The management team in Exeter and east had not implemented a lone working risk assessment. Lone working procedures were not consistent or effective in the east, north and mid services.
• Staff were using two separate recording systems. There was a risk that information about people would be lost or not updated because the two systems did not interact with each other.
• Technical delays in setting up remote access to internal data systems for recording information was an issue in the intensive assessment and treatment teams. For example, some staff could not update records in a timely manner.
• Training records showed that staff had not had training in the new mental health code of practice.
• Supervision records in the Exeter and east IATT were handwritten and filed together, meaning confidential information was not stored according to the Data Protection Act.
• The Devon Autism and attention deficit hyperactivity disorder (ADHD) service had waiting times averaging seven months for an ADHD assessment and 22 months for an ASC assessment.
• There was a lack of evidence for measuring service delivery outcomes via key performance indicators in the intensive assessment and treatment teams where the manager post was vacant or newer managers were in post.

We rated Devon Partnership Trust as good because

• Assessments were comprehensive.

• Care plans were up to date, personalised, holistic and recovery oriented. They were outcome- focused and linked to risk assessments.

• Patient’s risks were being rated, prioritised and regularly reviewed and crisis plans were being created and used.

• Physical health checks had been carried out on admission.

• Caseloads were manageable.

• 99% of staff had received mandatory safeguarding training and staff demonstrated a good awareness of safeguarding procedures.

• We saw patients being treated with respect and dignity. We observed positive interactions between staff and patients and staff were compassionate and supportive.

• Staff involved patients in the planning of their care. We found the general approach was patient led and focused.

• Teams comprised of a full range of mental health disciplines and met regularly. All teams had weekly team meetings and monthly business meetings. These followed a standard agenda and were thorough and effective.

• Staff felt positive about the chief executive and senior management and felt heard by them.

• Staff were appraised and supervised.

• Managers and clinical leads demonstrated enthusiasm and imaginative problem-solving.

However:

• There were long waiting times for access to psychological therapies.

• Some teams were failing to meet referral to treatment targets. This meant some patients were having to wait to access treatment.

• Care records did not always show whether patients had given informed consent to their treatment. This included administration of depot medication.

• Medication was being stored in a fridge without a record of fridge temperatures being regularly checked.

• Lone working practices varied and systems for raising alarms were not always effective.

• Staffing levels varied and some teams had not been able to recruit experienced nursing staff.

• Morale varied and we were repeatedly told by staff that the pace and rate of change was stressful.

We rated mental health crisis services and health-based places of safety as requires improvement because;

• The Mental Health Crisis Care Concordat states “People in crisis should expect local mental health services to meet their needs appropriately at all times”. We found none of the teams we visited could offer any more than two visits a day to a patient and none after 9.30pm. Staff in North Devon told us they could not realistically offer an alternative to hospital admission and if they had significant concerns about a patient they would need to arrange an urgent inpatient stay.

• After 9.30pm teams relied on night nurse practitioners to answer the phone to patients. These staff had a range of other responsibilities to attend to at night such as on-site support and staffing the health based place of safety. Patients trying to contact the crisis teams for support could not be guaranteed their call would be answered in a timely fashion.

• The care plans we reviewed were standardised but not all were personalised or recovery orientated. Not all care plans we saw listed the interventions on offer, nor did they address how interventions would alleviate the patients’ crisis.

• None of the teams we visited were participating in any clinical audits.

• Physical health checks were not a standard part of the assessment process, but we saw how staff addressed patients' immediate physical healthcare needs.  

• The Police told us there were times when people were refused admission to the hospital based place of safety due to smelling of alcohol or a previous history of aggression. We were unable to substantiate this during our inspection due to a lack of records being made available.  Information provided by the trust as part of the accuracy process identified that of the times the place of safety was closed 65% of closures was due to lack of staff, 15% was due to the place of safety being used as an extra bed, 12% of closures were due to staff being required for observations elsewhere and 8% was a result of the patient being assessed as being too violent for admission to the place of safety.

However:

• The layout of all three health based places of safety enabled staff to observe patients safely whilst in the suites. We saw that there were ligature risk assessments undertaken by senior staff and risks were mitigated by the presence of staff at all times, who were able to constantly observe the patient.

• Each crisis team had a mid-day handover along with at least two bed management meetings per day. For the teams attached to the acute inpatient units the bed management meetings included ward managers and senior staff.

• The waiting times for all teams from referral to triage assessment were 4 hours for very urgent and 24 hours for routine cases. All the team managers showed us the systems they used for monitoring and reporting to ensure these timescales were met.

We rated acute wards for adults of working age as requires improvement because:-

• Some environment risks such as ligature anchor points had been identified on risk assessments. However, there were not clear timescales as to when these risks would be addressed.

• There was a high use of bank and agency staff on Haytor ward and both staff and patients raised concerns about staffing levels on the ward. This meant that there was a risk that people’s care was not well managed due to the staffing levels.

• Staff on Ocean View ward were not clear about how learning from incidents took place and had not received feedback which had led to changes in practice following incidents which had taken place on the ward.

• While physical health monitoring took place on admission, at The Cedars and Haytor ward, there was no record of ongoing physical health monitoring.

• Inpatients had poor access to clinical psychology as there were no psychologists based on the wards.

However:

• Staff delivered care in a kind, thoughtful and compassionate manner with attention to the privacy and dignity of patients.

• A high percentage of staff had completed relevant mandatory training.

• Ward managers had information available to them about training, supervision and appraisals of staff on the wards.

• The trust had taken action to ensure that beds were accessed in the most appropriate place and there was strong multi-disciplinary working on the wards.

• Staff mostly felt supported by the trust and the local management.

When aggregating ratings, our inspection teams follow a set of principles to ensure consistent decisions. The principles will normally apply but will be balanced by inspection teams using their discretion and professional judgement in the light of all of the available evidence.

We rated Devon Partnership NHS Trust as requires improvements because:

• Although the trust had made significant improvements following the last inspection we found some wards were unsafe due to features of their design and the way in which staff managed the risks that these posed. Some wards contained ligature anchor points, where patients at risk of suicide might attach a cord in attempt to strangle themselves. Staff had identified some of these ligature points but had not taken appropriate action to mitigate the risks. In other cases, staff had not identified the ligature points. We were particularly concerned about the risk of ligature points on Haytor ward and Moorland and Ocean view. The layout of some wards meant that there were parts of the ward that staff could not easily observe from the nursing office. These ‘blind spots’ were places where patients at risk might harm themselves without staff seeing them. The trust had identified this as a risk on Haytor ward twelve months ago but had not taken action to address the problem. The trust did have an action plan in place to address these issues, but there was not a date identified when all of the issues would be addressed.
• The difficulties that the trust had in recruiting staff had resulted in an adverse impact on patient care. In some services, 30% of posts were vacant. This was a particular problem across the forensic estate, where both staff and patients raised concerns about staffing levels. The mental health wards employed agency and bank nurses to cover a high proportion of shifts.
• Patients care plans varied in detail and quality. They were not always person centred and they lacked detail required to demonstrate an understanding of the patients’ circumstances and needs.
• The quality of clinical care was not consistently high across all services. Medical and nursing staff at the Cedars, Haytor ward and in the community mental health services for older people did not assess or monitor the physical health of patients adequately. Many patients did not have easy access to psychological therapies. This was partly because some services had limited access to a psychologist. Clinical staff did not consistently use structured assessment tools to assess patients or measure outcomes of care.
• Staff did not always document patients’ active involvement in their care planning and/or giving of their consent. For example, treatment escalation plans for patients on Belvedere ward were not individual and were written in a blanket way. They did not clearly set out how the decision-making process, regarding the person’s capacity, was made.
• Some of the trust’s services were not sufficiently accessible or responsive to patients. The mental health crisis teams did not offer a comprehensive round-the-clock service. They did not always have sufficient numbers of staff to assess new patients promptly and could not visit a patient more than twice a day. The crisis teams operated until 21.30 hours. After this time, the only crisis response was a night nurse practitioner. This nurse had other competing duties and so might not be available to pick up the phone. In the additional support unit, we found several complaints raised about the standard of food served, food was brought in from an internal caterer using a cook/freeze approach, in response to previous complaints about the food on the ward.
• There was a backlog of complaints, meaning that staff could not address themes or learning in a timely manner. Some clinical teams did not have a process in place for ensuring that staff learnt these lessons from incident or complaint investigations.

However;

• The trust continues to build on the improvement programme. There had been significant improvements made and the trust had a clear strategy for further improvement that, although in its infancy, was well considered and project managed. The seclusion rooms, highlighted as a key concern during the last inspection, had been improved by providing staff with necessary training and skills in most services.
• We found that in most core services there were risk assessments in place that were comprehensive and holistic. Staff understood the local safeguarding procedures, and how they could raise concerns. Most services could demonstrate they used evidence based practice and followed national guidance. We observed staff across all core services providing skilled interventions in a caring and respectful way. The wards and community bases were, in the main, clean and staff checked and addressed infection control issues as necessary.
• Teams were multidisciplinary and worked collaboratively to provide care and treatment. Monthly supervisions and annual appraisals were well documented and, in the main, up to date. The trust had achieved an average of 83% compliance across the 12 mandatory core training courses.
• The inspection team recognised that the trust was well led with leadership, management and governance systems in place. Most staff felt positive about the chief executive and senior management team and felt they heard their views. We saw that the trust supports learning and promotes an open culture where staff are encouraged to participate and engage in service developments and change. Senior management had an understanding of the strengths and weaknesses of their service and the governance systems allowed them to report on this accurately.
• There was a strong culture of staff managing complex patient behaviours effectively, using restraint and medication only when needed. Staff understood de-escalation techniques, avoiding the use of physical interventions as much as possible. 

We rated the additional support unit at Whipton Hospital as requires improvement because:

• We found that patients were not read their rights under Section 132 of the Mental Health Act and there was a lack of accessible information about how to access an independent mental health advocate.

• Positive behavioural support planning was not embedded into patients’ care and support.

• There were no activity schedules on display to show patients the planned activities during the week. Staff on site were not engaging patients in meaningful activities during our visit.

• We heard and saw that patients were not happy about the quality of their food. There were concerns from patients about the nutritional value of the food, the times meals could be eaten and the temperature of the food. We saw that patients were not encouraged to prepare their own food. The raised vegetable patch that had once been used by patients was overgrown and not in use.

• The seclusion room did not have toilet and washing facilities. The extra care area toilet facilities were not adequately ventilated.

• Although patients had their own bedrooms, the ward was noisy with a lack of quiet areas and recreational areas indoors or outdoors.

• There was a disproportionate number of nursing assistants employed, who alongside regular agency staff, did not fulfil the duties required to meet the needs of the patients on the unit.

• The staff were not clear about the recently updated seclusion and segregation policy.

• The managers did not receive enough support from the rest of the multidisciplinary team to share their skills and knowledge throughout the team. For example, the psychiatrist could talk to us about positive behaviour support but the nurses lacked knowledge in this area. The management team could talk to us about the differences between seclusion and segregation but the rest of the team were confused about the difference. There were over 20 nursing assistants employed but they did not have the skills to complete the activities required to meet the needs of the patients.

• The management team had noted the complaints about food provision but had not acted upon them.

• The blanket restrictions in place meant the ward was not set up to promote recovery and independence.

However:

• The wards were very clean and parents and carers of patients told us they believed their family member was in a safe environment.

• Staff regularly assessed and updated risks onto shared data information systems.

• Managers shared learning outcomes from adverse events in staff meetings, which were well documented.

• Mandatory training was at 94% compliance.

• Every patient had a mental capacity assessment which staff regularly reviewed. Staff had a good working knowledge of the Mental Capacity Act and Deprivation of Liberty Safeguards.

• Records showed staff were supervised every month, and had annual appraisals.

• Staff were caring, kind, respectful and well thought of by parent and carers.

• Patients had their own easy read care plans and the team made good efforts to adapt documents so that they were accessible.

• There were no waiting times for treatment and discharge planning was thorough.

• Staff, patients and families knew how to complain and comments books were easily available.

• Staff talked positively about their manager and the senior management team.

Devon Partnership NHS Trust is the main provider of mental health services in Devon. The trust covers Devon County Council and Torbay Unitary Authority, which have a combined population of 890,000 people. The trust employs around 2,500 staff, has an annual budget of £130 million and supports almost 18,000 people at any one time.

The trust has three acute inpatient services at Wonford House Hospital in Exeter, North Devon Hospital in Barnstaple and Torbay Hospital. In addition there are other inpatient services provided at Whipton Hospital, Franklyn Hospital and Langdon Hospital which are located around Exeter. Most of the services are provided to people who live in Devon but a few specialist services also support people from other parts of the country. These include services for people with a learning disability, eating disorder or those who need secure mental health services.  Community mental health teams are situated throughout Devon. During this inspection we visited the following services:

Torbay

Haytor Ward: Acute Admission Ward – adults of working age  

Beech ward: Acute Admission Ward – older people

North Devon 

Ocean View: Acute Admission Ward – adults of working age

Moorland View: Acute Admission Ward – adults of working age

Meadow View: Acute Admission Ward – older people

Franklyn Hospital

Belvedere ward: Service for older people

Rougemont ward: Service for older people

Wonford House Hospital 

Delderfield: Acute Admission Ward – adults of working age

Coombehaven: Acute Admission Ward – adults of working age

The Haldon: Specialist eating disorder service

Community Services

Community mental health services providing support for people in crisis in recovery, people with learning disabilities and older people 

Whipton Hospital

Additional Support Unit: Service for people with learning disabilities

Langdon Hospital Dewnans Centre

Ashcombe: Forensic / secure services

Holcombe: Forensic / secure services

Warren: Forensic / secure services

Cofton: Forensic / secure services

Langdon Hospital

Avon House: Forensic / secure services

Chichester House: Forensic / secure services

Owen House: Forensic / secure services

Connelly H ouse: Forensic / secure services

CQC has inspected all of the trust’s locations in the last two years. Inspections of the acute services in Exeter in November 2013 and the secure services at Langdon Hospital in September 2013 had both resulted in compliance actions. The trust had prepared action plans in both these areas and we checked their progress as part of this inspection. We found that the Exeter acute services were not yet involving patients in the preparation of their care plans or making a copy available to them. They were also not ensuring people had regular access to their named nurse. The action plan for these services said that these improvements should have been in place before this inspection, so we have taken enforcement action. 

We reinspected on 21 May 2014 to monitor compliance with the warning notice issued as an enforcement action against Wonford House Hospital and found that the required improvements in respect of the warning notice had been made.  We did not follow-up other areas of non-compliance at this time as the trust was still in the process of implementing improvements and we will monitor these.

We observed staff supporting patients with care and compassion and a high level of commitment to providing a good quality service. We also found a trust that is committed to providing safe care with a strong recovery focus. The trust is an open, honest and learning organisation that works well in collaboration with other stakeholders. There are also examples of good and outstanding services – especially in some of the specialist provision.

However, the trust had a number of significant challenges, especially in the provision of responsive services for adults of working age needing acute care:

• Places of safety – too many patients in crisis were being taken to police stations or to the local emergency department rather than to the trust’s own Section 136 suites (which are the designated health-based places of safety) – especially in the Exeter and Torbay hubs.
• Access to section 12 doctors who are approved to assess patients who may need to be detained under the Mental Health Act – this was variable across the trust, resulting in some acutely unwell patients waiting a long time to be assessed – especially in Exeter.
• Out-of-hours support to patients – at night the only crisis team response was an out-of-hours nurse practitioner who has a wide range of roles. Patients and carers have no effective way of contacting this practitioner directly. When they are away from the office (which they often are), the caller has to leave a message on an answer phone that might not be picked up until the crisis team start work in the morning. Junior doctors working out of hours are very stretched, especially in the Exeter area where they cover inpatient services across a wide area.
• Bed management – there were three acute inpatient services with variable lengths of patient stay. Average bed occupancy was 92% and often no bed was available for a new admission. This results in some patients being admitted to a bed in a part of Devon that is a long way from their home. This problem was most severe in South and West Devon and in Torbay. In Torbay Hospital the older adult acute inpatient ward had 40% of beds occupied by working age adults although a significant number of these were over the age of 50.
• There is no psychiatric intensive care unit (PICU) in Devon. As well as leading to patients being admitted to a bed far from their home, senior nursing staff spend many hours of their time trying to find an available bed. Patients can also wait many hours, and in some cases days, in seclusion for appropriate care if clinically 

Other significant challenges are as follows:

• Patients, including those who have previously presented to the crisis teams, were being held and risk assessed by staff in community mental health teams while waiting, in some cases for several months, to be allocated to a recovery team care co-ordinator. This means that whilst individual cases are prioritized and their safety is being monitored, they are not getting the treatment and support they need.
• Access to psychological therapies – the trust had a large waiting list for step 4 psychological therapies (over 700 people in Exeter, over 200 people in Torbay and over 100 in North Devon). This has an adverse effect on care and treatment. The Trust has implemented a new two-tier approach to the provision of psychological therapies but this has not been applied consistently across the trust.
• Engagement with staff – this remained patchy. The trust is aware of this and has started a Listening into Action programme, which staff felt would lead to some very practical solutions to improve the service. There is, however, further work to be done to support engagement as some staff teams feel very involved and others removed.
• Although there was a good programme of induction, mandatory and ongoing training in place, there were some areas where further training is needed. For example, training on the use of physical interventions was too low on a few wards. Some staff also told us that they had received training to provide them with an additional skill, but did not have the time to use this.
• Quality monitoring – some staff teams are making good use of the results of quality audits and others just see this as focusing on ‘targets rather than quality of care’.
• Use of seclusion – one seclusion room in Torbay was in a potentially unsuitable location on a suspended ward and ‘extra care areas’ were sometimes being used for seclusion without this being recognised at Langdon. We found that some recording of the use of seclusion is poor and this makes it hard to monitor its use across the trust.
• Involving people in the development of their care plan – this was very mixed across the trust and in a few areas there was little evidence of this taking place.
• The quality and quantity of food provided for patients at North Devon District Hospital and Langdon Hospital was poor.

Devon Partnership NHS Trust is the main provider of mental health services in Devon. The trust covers Devon County Council and Torbay Unitary Authority, which have a combined population of 890,000 people. The trust employs around 2,500 staff, has an annual budget of £130 million and supports almost 18,000 people at any one time.

The trust has three acute inpatient services at Wonford House Hospital in Exeter, North Devon Hospital in Barnstaple and Torbay Hospital. In addition there are other inpatient services provided at Whipton Hospital, Franklyn Hospital and Langdon Hospital which are located around Exeter. Most of the services are provided to people who live in Devon but a few specialist services also support people from other parts of the country. These include services for people with a learning disability, eating disorder or those who need secure mental health services.  Community mental health teams are situated throughout Devon. During this inspection we visited the following services:

Torbay

Haytor Ward:  Acute Admission Ward – adults of working age  

Beech ward:  Acute Admission Ward – older people

North Devon 

Ocean View: Acute Admission Ward – adults of working age

Moorland View:  Acute Admission Ward – adults of working age

Meadow View:  Acute Admission Ward – older people

Franklyn Hospital

Belvedere ward:  Service for older people

Rougemont ward:  Service for older people

Wonford House Hospital 

Delderfield:  Acute Admission Ward – adults of working age

Coombehaven:  Acute Admission Ward – adults of working age

The Haldon:  Specialist eating disorder service

Community Services

Community mental health services providing support for people in crisis in recovery, people with learning disabilities and older people 

Whipton Hospital

Additional Support Unit: Service for people with learning disabilities

Langdon Hospital Dewnans Centre

Ashcombe: Forensic / secure services

Holcombe:  Forensic / secure services

Warren:  Forensic / secure services

Cofton:  Forensic / secure services

Langdon Hospital

Avon House: Forensic / secure services

Chichester House:  Forensic / secure services

Owen House:  Forensic / secure services

Connelly H ouse:  Forensic / secure services

CQC has inspected all of the trust’s locations in the last two years. Inspections of the acute services in Exeter in November 2013 and the secure services at Langdon Hospital in September 2013 had both resulted in compliance actions. The trust had prepared action plans in both these areas and we checked their progress as part of this inspection. We found that the Exeter acute services were not yet involving patients in the preparation of their care plans or making a copy available to them. They were also not ensuring people had regular access to their named nurse. The action plan for these services said that these improvements should have been in place before this inspection, so we have taken enforcement action.

We observed staff supporting patients with care and compassion and a high level of commitment to providing a good quality service. We also found a trust that is committed to providing safe care with a strong recovery focus. The trust is an open, honest and learning organisation that works well in collaboration with other stakeholders. There are also examples of good and outstanding services – especially in some of the specialist provision.

However, the trust had a number of significant challenges, especially in the provision of responsive services for adults of working age needing acute care:

• Places of safety – too many patients in crisis were being taken to police stations or to the local emergency department rather than to the trust’s own Section 136 suites (which are the designated health-based places of safety) – especially in the Exeter and Torbay hubs.
• Access to section 12 doctors who are approved to assess patients who may need to be detained under the Mental Health Act – this was variable across the trust, resulting in some acutely unwell patients waiting a long time to be assessed – especially in Exeter.
• Out-of-hours support to patients – at night the only crisis team response was an out-of-hours nurse practitioner who has a wide range of roles. Patients and carers have no effective way of contacting this practitioner directly. When they are away from the office (which they often are), the caller has to leave a message on an answer phone that might not be picked up until the crisis team start work in the morning. Junior doctors working out of hours are very stretched, especially in the Exeter area where they cover inpatient services across a wide area.
• Bed management – there were three acute inpatient services with variable lengths of patient stay. Average bed occupancy was 92% and often no bed was available for a new admission. This results in some patients being admitted to a bed in a part of Devon that is a long way from their home. This problem was most severe in South and West Devon and in Torbay. In Torbay Hospital the older adult acute inpatient ward had 40% of beds occupied by working age adults although a significant number of these were over the age of 50.
• There is no psychiatric intensive care unit (PICU) in Devon. As well as leading to patients being admitted to a bed far from their home, senior nursing staff spend many hours of their time trying to find an available bed. Patients can also wait many hours, and in some cases days, in seclusion for appropriate care if clinically 

Other significant challenges are as follows:

• Patients, including those who have previously presented to the crisis teams, were being held and risk assessed by staff in community mental health teams while waiting, in some cases for several months, to be allocated to a recovery team care co-ordinator. This means that whilst individual cases are prioritized and their safety is being monitored, they are not getting the treatment and support they need.
• Access to psychological therapies – the trust had a large waiting list for step 4 psychological therapies (over 700 people in Exeter, over 200 people in Torbay and over 100 in North Devon). This has an adverse effect on care and treatment. The Trust has implemented a new two-tier approach to the provision of psychological therapies but this has not been applied consistently across the trust.
• Engagement with staff – this remained patchy. The trust is aware of this and has started a Listening into Action programme, which staff felt would lead to some very practical solutions to improve the service. There is, however, further work to be done to support engagement as some staff teams feel very involved and others removed.
• Although there was a good programme of induction, mandatory and ongoing training in place, there were some areas where further training is needed. For example, training on the use of physical interventions was too low on a few wards. Some staff also told us that they had received training to provide them with an additional skill, but did not have the time to use this.
• Quality monitoring – some staff teams are making good use of the results of quality audits and others just see this as focusing on ‘targets rather than quality of care’.
• Use of seclusion – one seclusion room in Torbay was in a potentially unsuitable location on a suspended ward and ‘extra care areas’ were sometimes being used for seclusion without this being recognised at Langdon. We found that some recording of the use of seclusion is poor and this makes it hard to monitor its use across the trust.
• Involving people in the development of their care plan – this was very mixed across the trust and in a few areas there was little evidence of this taking place.
• The quality and quantity of food provided for patients at North Devon District Hospital and Langdon Hospital was poor.