Devon Partnership NHS Trust

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led - This means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last inspection we rated this key question Good. At this assessment, the rating has changed torequires improvement.

We reviewed all the quality statements for the well-led key question.

This service scored 39 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff members told us about the trust’s vision and values. However, they told us leaders did not always demonstrate a positive listening culture that promoted trust and understanding to support learning and improvement. Staff told us senior leadership were moving towards a shared direction and culture, but this was not yet embedded. Staff said the culture had recently started to improve.

The provider had a shared vision, strategy and culture which was based on transparency and human rights. The aims of the ASU, as per the trust’s standard operating procedure, was to provide a safe and therapeutic setting, but it was not always being met, and people were not always benefiting from it.

Although people and their representatives were involved in decisions about their care and treatment, the delivery of people’s support indicated a poor culture, with high levels of restrictions and potential injury to people and staff.

There was no consideration to the risks associated with closed cultures and no active discussions were taking place so they could be quickly identified. The challenges and needs of people were not always recognised and addressed to promote a positive culture. This meant people were not always at the centre of their support.

During the inspection, ward managers and senior leaders were honest and open about the current situation and challenges the service was facing. The environment needed work, and people were being delayed at the point they were ready for discharge. However, there was not sufficient oversight by the trust to ensure the ethos, values, attitudes and behaviours of leaders and staff meant people could lead confident, inclusive and empowered lives. People were not always treated with dignity and respect.

There were policies and processes in place promoting a positive working environment, but they had not always been successful and there was a lack of inclusive leadership.

There was a focus on how leaders could identify examples of poor culture that may affect the quality of people’s care and have a detrimental impact on staff, but the process had failed. Staff from the senior leadership team visited the wards but had not identified the shortfalls we found, and staff told us leaders had not always listened to them. There were examples of poor culture that were affecting the quality of people’s care and leaders had not taken action until we raised concerns.

Staff said they had not previously felt listened to or that action would be taken to address their concerns. One staff member said, “I had to go to the freedom to speak up guardian as no one was listening to me.” Staff told us changes to the senior leadership team had introduced a more open culture and they were now being encouraged to raise concerns to promote the wellbeing of people and staff.

The trust’s processes had failed to identify staff did not feel they could speak up and their voices heard. Although the freedom to speak up policy had been used by staff, there had been a significant impact on safety and quality of care and treatment people had received.

There were networks that staff could be involved in, such as ethnic minorities, disability, and long-term conditions, LGBTQI, menopause, mental health, neurodivergent and working carers. Staff undertook equality, diversity and inclusion training. None of the staff raised any concerns with us about equality, diversity or inclusion within the staff team.

The trust told us they valued diversity in their workforce and were working towards an inclusive and fair culture by improving equality and equity for staff.

Staff and leaders were supported to care for people using the service.

The trust had policies that focused on inclusion and working to ensure people and staff’s protected characteristics were met and supported.

The trust had a ‘Together Programme’ which provided a framework and guide for working collaboratively. The trust was committed to embedding this into everyday practice, including when planning to develop and improve services.

Staff were not supported to have clear responsibilities, roles or systems of accountability. Leaders did not act on information about risk raised to them from staff or share this with others when appropriate.

The leadership team shared a ‘Trust Wide Learning Report’ from late 2023. Some of the areas in the report reflected the concerns we found at the hospital such as, lack of debrief impacting staff wellbeing and an increase in sexual safety incidents. There was no indication any learning had been taken from this to improve the safety and quality of people’s care and treatment at the ASU.

The trust had clear governance processes appropriate for the service, but they had failed to identify the shortfalls we found. For example, there was a restrictive practice audit, and managers were supposed to review and sign off incident reports, but there had been a failure to recognise restrictive practices were not always being used as a last resort.

There was no evidence to provide assurance as to how the trust would ensure, at the time of crisis, staff were applying their learning, providing a skilled response, and following people’s care plans.

Following our site visit we asked the trust to take immediate action to keep people safe. We were not assured by their response, so we took urgent enforcement action.

The service had a business continuity plan which enabled a team to maintain service delivery during a declared business continuity, critical or major incident.

People had not consistently been supported and enabled to enjoy their lives, thrive, develop skills, have new experiences and live the life they choose.

Leaders worked alongside a variety of external partner agencies such as the ICB and Local Authority to review and monitor the care and treatment people received. There were regular meetings with and about people to review their support. Each person underwent a Care and Treatment Review (CTR) to review their legal status to be at the ASU and these were held in partnership with people, their family, advocate’s and professionals. The CTR outlined the summary of the actions and recommendation to be taken together with an action update.

We received no feedback from partners as part of the assessment in this area.

The ASU formed part of a whole system approach and focused on intensive interventions and short stays. Commissioning and service delivery was overseen by a comprehensive set of policy guidance that set out a clear framework for learning disability services. This included the Learning Disability Mortality Review (LeDeR) Programme as well as National Institute of Care and Health Excellence (NICE) guidance.

Staff and leaders collaborated with all relevant external stakeholders and agencies and worked in partnership with key organisations to support care provision, service development and joined-up care. However, due to the lack of governance and oversight, concerns about people’s distress and the level of restrictions imposed on people were not always discussed. This meant the multi-disciplinary team was not able to then review and assess people’s distress and consider a collaborative approach to supporting people.

There were missed opportunities for staff and leaders to engage with people, communities and partners to share learning and lead to better outcomes for people.

There was not always a focus on continuous learning, innovation and improvement across the organisation and local system. Staff were not enabled to be creative in ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice. There was no evidence staff had considered if an incident was related for example, to an unmet need, boredom, or an enjoyment of the response they gave and received.

Staff did not always fully recognise or consider the risks posed by people against each other. It was not clear on reviewing incident forms why ‘as required’ medicines for medical restraint was the treatment given to people.

There was not always a culture of continuous learning and improvement. The provider’s process had failed to identify this and had not identified that staff responded differently when managing people’s day to day needs and distress.

Safety was not always managed or monitored effectively. The approach to identifying and managing restrictive practises was not proactive and did not keep people safe.

One person’s care plan had not been updated even though it was documented they continuously tried to enter another person’s room. There was no consideration as to whether this was an ongoing concern.

There was a ‘you said, we did’ system, which was displayed on an easy read poster. It captured what people had told the staff, then what the staff had done about it. There were some positive examples of where people had wanted menu changes or different activities. However, further work could have been done to listen to people and consider what changes could be made to better meet their individual needs.