Devon Partnership NHS Trust

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• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

This means we looked for evidence that the service met people’s needs.

This is the first assessment for this newly registered service. This key question has been rated good. This meant people’s needs were met through good organisation and delivery.

Staff managed beds well. Patients were not moved between wards except for their benefit. Patients did not have to stay in hospital when they were well enough to leave. The design, layout, and furnishings of the ward supported patients’ treatment, privacy and dignity. Staff supported patients with activities outside the service, such as work, education and family relationships. The service met the needs of all patients – including those with a protected characteristic. Staff helped patients with communication, advocacy and cultural and spiritual support. The service treated concerns and complaints seriously, investigated them and learned lessons from the result.

This service scored 64 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure people were at the centre of their care and treatment choices and they did not always work in partnership with people, to decide how to respond to any relevant changes in people’s needs.

We saw that inconsistency in staffing was delaying care delivery and affecting the continuity and responsiveness of person-centred care. Individual efforts by certain staff members at the service was the mechanism for delivering person-centred care rather than reliable systems pathways. Staff were aware of not overloading a person with information and where to position themselves in relation to people with visual difficulties. Whiteboards and an easy read document about vaping were used as a communication adjustment for a patient.

Staff turned off lighting when a person accessed communal areas where they were engaging with staff and completing a puzzle because the person was sensitive to lighting. The lights were also turned off in their private space, which was naturally lit by sunlight. We saw that people’s communication passports included detailed information about the person's ability to receive and express information and guidance for staff about how to support them. Staff had guidance on how to phrase choices to maximise each person's sense of empowerment and control included a 'now and then' approach to encouraging everyday living skills.

The service had a faith room set aside as a music space on Wednesday lunchtimes for patients and staff and equipped with instruments. The Chaplain had created easy read guides on a range of spiritual issues and produced a faith formulation in collaboration with the psychologist, patients and parents which informed peoples’ support plans.

However, we also observed little interaction between agency staff and a person on 2:1 observation. There was limited evidence that people were being supported to take up hobbies specific to their interests or to try new things. Activities that had been undertaken were limited to puzzles, playing catch, colouring, vaping, going to the local shops and driving to the beach.

Following high level feedback provided at the end of the inspection the trust advised the new interim senior nurse manager and quality improvement lead will lead MDTs to coordinate a quality review of all patient care plans to include activity planning that meets patients’ needs'.

We scored the service as 3. The evidence showed a good standard. The service understood the diverse health and care needs of people and their local communities, so care was joined-up, flexible and supported choice and continuity.

Staff supported patients to maintain contact with their families and carers and this was documented in their care records. We saw that communication from patients’ carers and family were recorded prior to their MDT and carers were invited on the ward and to MDTs.

Staff supported patients to access their chosen place of worship within the community, and the service had drafted faith formulations for patients. Service occupational therapists planned patients’ discharge and tracked community discharge outcomes for each person. The service’s TRiM counsellors had been introduced to follow up patients 1 month after discharge to ensure they had established effective links to community groups.

We scored the service as 3. The evidence showed a good standard. The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

Information governance systems included confidentiality of patient records. Staff told us that they accessed patient records on a need to access only. The service complied with the Accessible Information Standard. There was evidence of the service making information accessible to format to suit the patients in easy read and through visual boards. Staff ensured that patients could obtain information on treatments, local services, patients’ rights, how to complain and so on. Staff ensured carers, families and commissioners were regularly updated about the patient’s progress. Evidence of carers being invited to MDT reviews was captured in care notes.

We scored the service as 3. The evidence showed a good standard. The service made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. They involved people in decisions about their care and told them what had changed as a result.

The service has received only 1 formal complaint in the last 12 months. The complaint was resolved locally and did not proceed to the Ombudsman. We saw that staff received feedback on the outcome of investigation of complaints and that changes had been made because of complaint feedback. The patient had emailed their concerns to the patient experience team (PET)and the community support team and had received feedback and a formal response. The service changed procedure to ensure all multidisciplinary team (MDT) meetings and personal protection and support plans (PPSP) were reviewed by the clinical lead on the basis of family, patient and staff feedback. It also simplified the format and frequency of MDTs.

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure that people could access the care, support and treatment they needed when they needed it.

One person's dental appointment had been cancelled by staff due to confusion about the plan, meaning no staff were available on the day to support the appointment. Poor planning resulted in the person's painful toothache being prolonged. At the time of the inspection a new date for a general anaesthetic procedure to treat the persons dental issue had not been agreed. A pain scale had been implemented for the patient, but there was also no workable plan in place to reduce the person’s pain in light of national stock shortages of suitable medicine.

The entire service had responsible clinician cover for only 2 days each week. An additional 0.5 whole time equivalent (WTE) Multi Professional Approved Clinician(MPAC) was in post, but was off sick, and a trainee MPAC was on maternity leave. Fulltime medical cover has been in place since the appointment of a physical health doctor in January 2026, supplemented by the out of hours on-call doctor service for emergencies. In response to feedback given at the inspection that consultancy cover was inadequate, the trust advised recruitment was already underway for an additional 2 part time Psychiatrists at 0.5 WTE each with interviews to be conducted on 13 March 2026.

Discharge had been delayed on 2 occasions for non-clinical related reasons. One person was discharge ready but had been waiting 2 months for a suitable community placement. Staff noted that delays to discharge were due to misunderstandings in multi-agency agreements, a lack of community care providers in the Devon area and housing shortages. Staff told us the service needed to develop a discharge pathway which included a collaborative agreement signed by relevant multi-agency groups. This was not currently in place.

Following feedback provided during the inspection, the chief nursing officer initiated a fortnightly executive-led oversight meeting to monitor the action plan in place and support improvements to the service.

We scored the service as 3. The evidence showed a good standard. Staff and leaders actively listened to information about people who are most likely to experience inequality in experience or outcomes and tailored their care, support and treatment in response to this.

Ninety-seven per cent of staff were trained in equality, diversity, inclusion and human rights. Staff within the service promoted a culture in which the people using the service felt empowered to give their views. There was a health and safety champion, 2 safeguarding leads and one suicide prevention lead. There were 6 infection control champions and 3 communication champions. 2 staff champion civility and 5 staff were involved in reducing restrictive practice. The service had a family and carers team, a physical health team, a staff induction champion, and an administration champion to oversee compliant system use. There were multiple health and wellbeing champions, a sustainability champion, 2 smoking cessation champions, 3 physical intervention champions and 2 patient feedback champions.

The provider had undertaken equality impact assessments of their policies and procedures to ensure they did not place vulnerable people or people with protected characteristics at a disadvantage. All policies had review dates.

We scored the service as 2. The evidence showed some shortfalls. People were not always supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

We saw in care records that staff had supported patients to make decisions about their care and treatment and their future, for example completed “Do Not Attempt Cardiopulmonary Resuscitation” (DNACPR) forms. Staff had created care plans to account for the patient’s needs, but these were prescriptive and had not captured the patient`s voice or demonstrated the patient`s involvement in those plans. Following feedback provided during the inspection, the trust told us that as a part of the service action plan, care plans would be reviewed. The chief nursing officer also initiated a fortnightly executive led oversight meeting to monitor the action plan in place and its improvements, as a result of all of the feedback provided.