Devon Partnership NHS Trust

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement.

The service did not always ensure people were safe across its forensic inpatient wards. This meant people were at risk of avoidable harm. Learning from incidents was not consistently shared across wards. Staff did not always update risk assessments, and care plans were not always updated or person-centred. People using the service did not consistently feel involved in their care.

The provider did not effectively review staffing establishments on the forensic inpatient and secure wards at Langdon Hospital in a timely way. Staffing levels were often stretched, particularly during periods of high acuity. Frequent redeployment of staff impacted care delivery and access to leave and activities. Although safer staffing levels were met, gaps in specialist training and inconsistent supervision limited staff development and their oversight of safety.

There was insufficient blind spot and ligature risk management across all 5 wards putting people at risk of harm. Staff we spoke with during our assessment struggled to locate the ligature risk assessment tools and did not understand what actions to take in response to conducting a ligature risk assessment.

Medicines were managed safely overall, though oversight of clinical item storage and disposal was not always well managed by staff. People using the service did not always feel involved in decisions about their medicines.

However, staff felt confident reporting incidents, and safeguarding concerns were managed appropriately. The ward environments were clean and secure. Infection prevention and control measures were well embedded, with strong audit outcomes and no recent outbreaks.

This service scored 44 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The forensic inpatient and secure wards at Langdon Hospital did not consistently have a proactive and positive culture of safety based on openness and honesty, in which concerns about safety were listened to, safety events were investigated and reported thoroughly, and lessons were learned to continually identify and embed good practices.

The service did not have a formal or consistent process to share learning from incidents across the forensic inpatient wards. While incidents were discussed at higher-level governance meetings, this was often in a data-driven or abstract way. There was no structured mechanism to escalate key learning points to senior leaders or to ensure learning was shared across all wards to prevent recurrence of events. It was difficult to identify key learning points as they were not shared in a structured or formal way. As a result, shared risks and learning opportunities were not consistently addressed service-wide, leaving gaps in safety improvement.

The service had participated in a research project led by undergraduate students at the trust, which used the Essen Climate Evaluation Schema. This is a tool designed to assess the social and therapeutic climate of forensic psychiatric settings. Data is collected on a yearly basis and is benchmarked against national data. While this demonstrated a willingness to engage in reflective practice, there was limited evidence that findings from this work had been embedded into service-wide learning or improvement initiatives.

Although the service had systems to collect feedback from people who used the service and their family or carers, engagement with these mechanisms was limited. A twice-yearly ‘patient survey’ was led by the Social Work Team across the forensic inpatient wards, with results contributing to national reporting via UNIFY (the online national single storage system for NHS data). However, during the inspection we found that only 23% of people using the service had responded to the most recent survey, limiting its effectiveness as a tool for driving improvement.

All staff had access to, and received training on, the trust’s incident reporting system. Staff who submitted incident reports received feedback following the review and closure of incidents, which supported individual learning. Staff told us they felt confident to report incidents and concerns, and there was a culture that encouraged openness and speaking up. This reflected a positive approach to safety and accountability at the individual level.

Staff completed mandatory training and had access to additional courses aligned with their professional interests.

The forensic inpatient and secure wards at Langdon Hospital were not consistently effective in working with people and partners to establish and maintain safe systems of care, in which safety was reliably managed, monitored, or assured. Gaps in the quality of risk assessments and discharge planning meant that continuity of care, particularly when people moved between services, was not always supported as effectively as it could have been.

We did not consistently find a proactive approach to discharge planning from the point of admission. Staff did not routinely review or update discharge plans, and there was limited evidence of discharge planning being embedded into care processes at the early stages. Some delays in discharge were attributable to system-wide issues, such as the availability of step-down beds and suitable community placements.

Risk assessments were completed on admission, but the quality of risk assessments varied significantly. Of the 13 records reviewed during the inspection, 7 demonstrated clear and significant concerns regarding the quality of risk assessments. These included examples of outdated or inaccurate documentation, lack of updates following incidents, missing care planning for identified risks, and risk assessments that did not reflect the current presentation or needs of the service user. Similarly, care plans were not consistently person-centred or reflective of individuals’ current needs, risks, or preferences. This limited the effectiveness of staff in supporting safe, effective, and responsive care.

However, admissions to the service were planned, and staff conducted robust assessments to ensure individuals met the clinical criteria for admission. Staff within the multidisciplinary team (MDT) told us they felt included in discussions about new admissions and that their professional views were respected. There were occasional delays in admission, often linked to bed availability. This was frequently impacted by delayed discharges and what people using the service described as slow progress through the care pathway, with some individuals reporting a sense of stagnation in their recovery journey.

Transfers between wards were generally well managed. Staff reported no concerns with internal transfers, and the service had mechanisms to involve people using the service in these processes, including participation in ward rounds and Care Programme Approach (CPA) meetings. Where appropriate, and with consent or under relevant legal frameworks, families and carers were also involved and kept informed.

The MDT reviewed all transitions and worked collaboratively with community teams, external agencies, and stakeholders to facilitate admissions, transfers, and discharges. This joint working approach supported continuity of care, although its impact was sometimes constrained by the broader systemic challenges affecting discharge pathways.

Staff reported being aware of how to escalate health concerns, which helped to keep people safe. They described effective liaison with partner agencies and health services to address the needs of people using the service. Staff also felt comfortable discussing individuals’ risks and needs openly, fostering a transparent environment for care delivery and planning.

As part of routine monitoring of the service, the Integrated Care Board (ICB) had raised no concerns with the Commission in relation to this quality statement.

There were no immediate safeguarding concerns raised during the inspection. We saw evidence staff made safeguarding referrals in a timely way, and staff demonstrated a clear understanding of their responsibilities in protecting people from abuse and improper treatment.

Staff reported feeling confident in recognising and reporting safeguarding concerns. They were familiar with the trust’s safeguarding policy and knew where to access it. People using the service told us they felt safe, and we observed respectful interactions between staff and people who used the service.

However, training compliance for safeguarding adults and children at level 3 varied significantly across teams. While some areas, such as psychology and senior staff groups had achieved 100% compliance, others, including physical health teams showed significantly lower rates, with only 50% of staff up to date with their training. Overall, most wards demonstrated compliance rates above 75%, but there remained variation that could significantly impact consistency in safeguarding practice across the service and put people at risk of harm.

The safeguarding lead for the Secure Services Directorate had recently retired, and recruitment was underway to appoint a Senior Safeguarding Practitioner for Secure Services Directorate based within the Trust’s central safeguarding team. In the interim, a temporary arrangement was in place for the social work lead to cover the safeguarding lead role; however, they continued to fulfil their substantive full-time role alongside these additional responsibilities. Safeguarding referrals were tracked and reviewed by the Trust’s central safeguarding team, and a Safeguarding Governance Report was presented weekly to the Trust’s executive team. While this reflected robust governance at the organisational level, staff reported there were gaps in the feedback loop to frontline staff. Due to the interim arrangements and centralised referral handling, safeguarding outcomes were not always effectively communicated back to ward teams.

We did not find consistent evidence that people who used the service were routinely involved in the development or review of their risk assessments and safety plans. A review of 13 records showed that risk assessments were not always up to date or revised following incidents or changes in presentation.

The quality of documentation varied, and the language used was not always reflective of person-centred care or collaborative planning. This was reflected in feedback from people who used the service, several of whom told us they had not seen their risk assessments and did not feel involved in their care.

We did not consistently observe the use of positive risk-taking as a structured part of individuals’ recovery. While the nature of the secure environment and the presence of blanket restrictions can limit opportunities for autonomy, we did see some examples where individuals were supported to take informed risks. Staff were able to explain the rationale for these decisions, but such practices were not embedded across the service.

The service used recognised structured professional judgement tools to support risk assessment and management. These included the HCR-20, a tool used to assess the risk of future violence; the DUNDRUM toolkit, which supports decisions around levels of therapeutic security and recovery; and the DASA (Dynamic Appraisal of Situational Aggression) tool, which helps predict short-term aggression risk. In addition, the service reported using Goal-Based Outcomes (GBOs) as part of personalised care planning. These were reviewed with the multidisciplinary team and intended to inform both risk management and positive risk-taking, although we did not consistently see this reflected in practice. For example, although DASA was used as part of the trust’s ‘Four Steps to Safety’ programme, we found limited evidence that DASA scores were incorporated into holistic, multidisciplinary risk assessments. In the 13 care records reviewed, risk management plans did not routinely reference DASA scores or demonstrate adaptation in response to daily changes in assessed risk.

However, where appropriate, and with consent or under relevant legal frameworks, families and carers were involved in discussions about risk and safety planning. This supported a more holistic approach to care, although the overall lack of involvement from people using the service in risk management strategies limited their effectiveness.

We identified significant concerns regarding the design and use of the seclusion and extra care area (ECA) at the Dewnans Centre. This space did not consistently promote privacy or dignity, particularly when more than 1 person was using the area at the same time. The layout and visibility of these environments did not support therapeutic engagement or uphold the principles of least restrictive practice. There were concerns of a lack of clear protocols for managing multiple occupancy in these areas. These issues contributed to an action plan request relating to Dignity and Respect, which requires the service to outline how they will address the concerns in the use of seclusion and ECA spaces.

Additionally, we found significant concerns regarding the management of blind spots and ligature risks. All wards had blind spots, particularly in the corners of the medium secure wards, which were triangular in shape. These blind spots limited staff visibility and were not effectively mitigated. Although CCTV cameras had been installed, they were not live-monitored, and there was no facility for real-time viewing from ward offices. This meant the cameras did not provide an effective safeguard. Staff cited relational security as a mitigation for blind spots, but this was not a reliable or consistent control, particularly on admission wards.

It was reported that key holders conducted walkarounds to assess ligature risks, but staff did not demonstrate a good understanding of what they should be looking for or assessing. We also found that staff did not consistently complete full observation rounds and, in some cases, did not understand their purpose. The service did not have a formal blind spot management policy or risk assessment.

These gaps placed both staff and people using the service at risk of harm due to undetected environmental hazards.

However, the ward environments were visibly clean and generally well maintained. During our inspection, we observed some items required repair or maintenance; these had been reported to the estates team and were recorded on the environmental audit register. This demonstrated that staff were aware of environmental issues and took appropriate steps to address them.

The wards were secure for the level of risk presented by the hospital’s population. We did not identify any concerns with access control, internal security, or perimeter security. However, staff did not demonstrate confidence or a clear understanding of search policies and procedures, or in identifying and managing ligature risks.

Despite these concerns, the overall ward environments appeared therapeutic and recovery oriented. People using the service had access to outdoor spaces, activity rooms (both on and off the ward), and quiet or sensory rooms. The wards were spacious and did not feel cramped. People we spoke to did not raise any concerns about the environment and reported feeling safe and comfortable on the wards.

Staff reported when acuity of people using the service increased, the corresponding need for additional staffing to maintain ward safety was often difficult to meet. As a result, ward managers frequently had to step into frontline roles, which meant they did not always have protected time for their managerial duties. Staff across the secure wards also noted that they were regularly redeployed to cover shifts on other wards, often at very short notice. While redeployment was necessary to ensure safety across the secure wards, it often created staffing gaps elsewhere. Consequently, leave and activities for people that used the service were occasionally postponed or cancelled due to staffing shortages and operational pressures.

It was reported to us by both staff and people who used the service that, at times, there were not enough staff on duty to meet the needs of the ward population, including the availability of therapeutic activities and access to leave. However, the trust provided evidence the service was adhering to NHS safer staffing guidance, which sets minimum staffing levels based on acuity and ward type. In response to feedback about staffing pressures, the service had begun reviewing staffing requirements using recognised tools, including the Mental Health Optimal Staffing Tool (MHOST), which supports data-driven workforce planning in mental health settings.

The lack of a proactive and responsive approach to workforce planning continued to place undue pressure on staff and compromised the quality and consistency of care provided to people who used the service.

People using the service reported that activities and leave were sometimes cancelled due to staffing shortages, which impacted their experience and recovery.

Training compliance varied across teams. While many staff were up to date with mandatory training, there were notable gaps in specialist areas. Staff had not received autism-specific training, which limited their ability to assess and manage risks for neurodiverse individuals and deliver person-centred care. There were examples within the hospital population of individuals with these needs. Staff also lacked training in non-clinical risk assessment, which impacted their ability to identify and mitigate environmental risks effectively.

Supervision compliance was inconsistent across teams. On Cofton and Warren wards, high sickness rates and vacancies had affected the availability of senior nursing staff, limiting opportunities for supervision. A vacant Band 6 post on Cofton was out for recruitment, and redistribution of available staff had been initiated to support operational leadership. Administrative support had also been allocated to improve supervision tracking. In some cases, completed supervisions were not correctly recorded, impacting reported compliance rates. Less experienced staff were being supported to improve documentation accuracy.

In the reception team, high sickness rates and the temporary absence of the team manager had disrupted supervision arrangements. The manager had since returned, and improvements were expected. The medical staffing team also faced challenges due to vacancies and sickness, and the supervision structure in this team was under review. Historical misclassification of managerial supervision as clinical had further affected data accuracy.

However, staff generally felt that skill mixes on the wards were appropriate. Ward managers and senior staff were able to fulfil their leadership roles when not required to cover frontline duties during periods of high acuity.

Findings in this section contributed towards an action plan request relating to staffing.

The service had effective infection prevention and control (IPC) measures across the forensic inpatient wards. Staff were aware of the trust’s IPC policies and procedures and knew where to access them. We observed hand hygiene information was clearly displayed above handwashing stations, and we did not identify any concerns with IPC practice during our inspection.

All wards were subject to an annual IPC audit, undertaken by the trust’s Advanced Nurse Specialists. For 2024/25, audit scores were: Ashcombe (92%), Chichester (93%), Cofton (100%), Holcombe (100%), and Warren (92%). The Cofton Dental Room, which is audited using a separate tool, achieved 96% for environmental design and cleaning, and 100% for management of dental medical devices. All identified actions had been completed, including improvements to signage and decluttering of surfaces.

The Facilities Team adhered to the National Standards of Cleanliness (NSOC). Bi-monthly NSOC audits consistently demonstrated compliance above the 90% target across all wards. Daily cleaning records for clinic rooms were also maintained and available for review. Audit findings were reported through the Directorate Physical Health Operational Group (PHOG), and ongoing monitoring of action completion was scheduled to be overseen by the Inpatient Audit Governance Group (IAGG), providing further assurance.

Staff reported receiving IPC related training, and each ward had designated IPC link roles to support good practice.

During our inspection, ward environments were visibly clean and well maintained. Personal protective equipment (PPE) was readily available and appropriately stored.

There were no recent reports of infectious disease outbreaks, and the service demonstrated a proactive and structured approach to maintaining good IPC standards.

Medicines were prescribed and given safely across the forensic inpatient wards. We did not find any ongoing concerns about medication errors or missed doses. When incidents did happen, they were reported properly and investigated by the service to support learning.

Medicines were stored securely and in the right conditions. We had no concerns about how medicines were kept or managed, including controlled drugs.

Medicines reconciliation was carried out in two parts: the admitting doctor completed the initial prescribing, and the ward doctor reviewed the medicines for safety and suitability. Pharmacists were involved in regular reviews and supported safe prescribing decisions.

Staff were trained to give medicines safely. Pharmacy staff provided training on medicines optimisation, including face-to-face sessions during induction and refresher training every two years. Health Care Assistants (HCAs) were trained to act as second signatories for controlled drugs, which helped improve safety.

The service had systems to support safe medicines use. These included regular checks of legal paperwork (T2, T3, and Section 62), monthly reminders for monitoring high-dose antipsychotics, lithium, and clozapine, and the use of recognised tools like the Glasgow Antipsychotic Side-effect Scale (GASS) template to monitor side effects.

However, we found some issues with how medical items were stored and disposed of. Some items were open and not dated, were out of date, and some sharps bins were not labelled or properly closed. These issues showed that more consistent oversight was needed. It was also not clear whether clinical items had been regularly audited, this increased potential of cross-contamination, accidental injury, and inappropriate use of clinical items.

People using the service did not always feel involved in decisions about their medicines. Some said they had received information about their medicines, while others had not. This meant people were not always supported to make informed choices about their medication.