Devon Partnership NHS Trust

Ratings - Wards for people with learning disabilities or autism

• Overall

  Requires improvement

• Safe

  Inadequate

• Effective

  Good

• Caring

  Good

• Responsive

  Good

• Well-led

  Requires improvement

Our view of the service

We carried out a responsive assessment in response to concerns shared with Care Quality Commission (CQC) regarding people’s care and treatment on the Additional Support Unit (ASU) after a Mental Health Review visit earlier in 2024.

Whipton Hospital is located on the outskirts of Exeter.The Devon Partnership NHS Trust had a specialist service called the Additional Support Unit (ASU). It was a service for men and women aged 18 years and over with learning disabilities and mental health problems whose needs could not be met within mainstream services, despite reasonable adjustments. The ASU was a 5 bedded unit and was supporting 4 people at the time of our assessment.

We reviewed 2 key questions, Safe and Well-led. We identified multiple concerns that indicated people were, or may have been, exposed to significant risk of harm and abuse.

The service did not consistently protect people from abuse and improper treatment. Staff did not always assess risks to people's health and safety or mitigate them where identified. People did not always have care plans to guide safe practice. Governance systems and audits were not effective in identifying or addressing areas for improvement.

We found breaches of regulation in relation to safe care and treatment and safeguarding. We took urgent enforcement action to keep people safe.

We have assessed the service against ‘Right support, right care, right culture’ guidance to make judgements about whether the provider guaranteed people with a learning disability and autistic people respect, equality, dignity, choices, independence and good access to local communities that most people take for granted.

People's experience of this service

Our visit to the hospital was unannounced. One person was on leave visiting their family overnight and 2 people were out. We met one person, but they became distressed with us being present and did not want us to stay on the ward with them. To try to understand people’s experiences, we also reviewed their records on site.

People were not treated in a dignified and respectful way. People's records demonstrated they were subject to significant restrictive practices and restraint. However, there was not always evidence to suggest why the restriction was used or if it was proportionate to the level of distress people were showing.

People were not always safeguarded from abuse and improper treatment. There was a failure to consider people’s future wellbeing through the repeated used of significant restrictions without evidencing legal or clinical justification, using least restrictive principles.

One person was subject to periods of seclusion in their ‘calm room.’ This is a room they used independently to help them regulate their emotions. Seclusion is when a person is in supervised confinement, isolating them from others, and preventing them from leaving. There was no consideration of the significant emotional and wellbeing impact of locking them in their calm space.

We observed positive interactions between staff and people during our site visit. One person returned from a trip out on their own, staff greeted them, and they had a positive interaction with staff, asking for support with their money before going out again. We observed an arts and craft space where someone had been working on a painting with staff support.

People were invited to meetings held about their care and treatment. Information was provided to people in different formats.