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

Safe - This means we looked for evidence that people were protected from abuse and avoidable harm. At our last inspection we rated this key question inadequate. At this assessment, we saw that the service had improved, and the rating has changed to requires improvement.

We reviewed three quality statements for the safe key question.

This service scored 47 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had recruited more staff since our last inspection and had increased the number of professionals working at the service and had a multidisciplinary team including doctors, nurses, occupational therapists, speech and language therapists and psychologists.

The provider had comprehensive positive behaviour support plans (PBS) in place now, as required. The PBS plans documented what actions staff must take to prevent people becoming distressed, what to do if the person does become distressed and to record how they de-escalate the situation. Staff could demonstrate why they needed to use more restrictive interventions, such as physical restraints and use of PRN medication, which is also called “as required medication”, not taken regularly by patients, which staff can use to help calm a person in distress.

We reviewed the care records and saw staff were documenting actions taken to support the person before using restrictive interventions. This meant the provider could review and learn from incidents to enable staff to work with people in the least restrictive way. Senior staff audited records to ensure that staff had recorded this information and that staff learnt from any trends or themes identified.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

The provider reviewed seclusion records to ensure staff followed the legal framework. People remained in seclusion for the shortest time necessary. We saw evidence of seclusion paperwork being completed to the correct standards. We reviewed the seclusion audit paperwork and saw that when staff identified issues, they created an action plan to address them. The action plan had an agreed timeframe for completion and an identified staff member responsible for ensuring it was completed. For example, when only one nurse was on duty, they could not complete the 2-hourly nursing review correctly, as it required two registered nurses to complete the review. The provider put an escalation process in place, so the staff could identify a second nurse to complete the nursing review correctly. The audit showed that the use of seclusion had reduced as a result.

The trust was auditing the use of PRN medication to ensure it was used appropriately and effectively. We saw the PRN audit for October 2024 and saw that senior staff had identified use of PRN medication had increased. The audit discovered it had increased because the multidisciplinary team had care planned using medication to help manage anxiety around community access. However, once the MDT team had reviewed this, they saw that it had not been effective and the service stopped using PRN to assist with community access.

Since the last inspection, we saw staff had received additional training in safeguarding, sexual safety and human rights to improve staff knowledge and understanding of safeguarding issues. Staff told us the training relating to safeguarding had been beneficial. Staff could explain how and what they would report as safeguarding. There was regular safeguarding supervision for staff and managers produced a monthly safeguarding report to review open safeguarding and any outstanding actions staff needed to complete.

We found that PBS plans had detailed information on causes of known behaviours and instructed staff how they should collect information, so that it could be reviewed to help improve people’s lives. We reviewed notes and saw staff were following this guidance. The PBS plans had sections on promoting positive behaviour and reducing restrictive practice.

Staff attended daily safety huddles where changes to the care plans, PBS plans and other relevant information was discussed.

Staff we spoke with told us the service had improved since our last visit. They said that the reduction in the number of people admitted to the service had meant they had more time for training and promoting positive behaviour, which has led to a reduction in incidents. Staff told us the daily safety huddles had given them a voice in how the trust runs the service and they felt more listened to and involved in people’s care and treatment. Staff told us that morale had improved.

The provider had a clear system in place to review how staff followed people’s care plans and PBS plans and how they documented this. People’s care records demonstrated what action staff took to de-escalate a person before using more restrictive interventions.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe and effective staffing during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.