Devon Partnership NHS Trust

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• 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

This means we looked for evidence that people were protected from abuse and avoidable harm.

This is the first assessment for this newly registered service. This key question has been rated good. This meant people were safe and protected from avoidable harm.

All wards were safe, clean, well equipped, well furnished, well maintained and fit for purpose. Staff assessed and managed risks to patients well. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. The service used systems and processes to safely prescribe, administer, record and store medicines. The service managed patient safety incidents well.

This service scored 69 (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 ward staff exhibited a positive culture of safety, based on documentation and honesty. Concerns about safety were being reported and escalated by care staff. However, staff did not always feel listened to and lessons were not being learned to continually improve safety. Staff cited high levels of staff leaving the service and high levels of sickness absence due to stress and injury and said some staff had become afraid to intervene in incidents. This was corroborated by a recorded 8% sickness absence rate and current vacancy rate above 20% at the service.

There had been 3 incidents involving moderate harm or above at the service in the last 6 months. All incidents involved patients striking staff or other patients. All incidents had been investigated and documented in an incident log. The incident log considered medication administered, restraint used and possible triggers for each incident. The incident log included recommendations for staff to manage potential future triggers.

Some staff told us they had been debriefed and received support after incidents in the form of “hot debriefs - is everyone ok?” These ‘hot debriefs’ are not recorded in the incident log. Other staff told us there had been repeated incidents involving injuries to staff every few days with no follow up or changes made to the service. Some staff believed managers at the service believe living the threat of patient violence is just part of the job. Following high level feedback provided to the service after the inspection, the service told us they were aware of these concerns and had asked the physical intervention team to repeat the physical intervention training to improve staff confidence, although no date had been set for this. Staff also told us they had tried to get a daily check-in going at 3pm for all staff, but this initiative to address staff wellbeing had not been well attended, due to the busyness of staff.

Staff told us they received feedback about incidents via manager’s email and through individual supervision. Where incidents had indicated additional training, skills enhancement or competency checks were required, these were discussed directly with the staff concerned. Various staff teams like nurses and occupational therapists held their own monthly meetings where themes identified by the risk management system (RMS) were discussed. The speciality doctor initiated the first quarterly forum specifically for Health Care Assistants in January 2026 shortly after being appointed, but this was also not well-attended due to the busyness of staff. The HCA meeting in January 2026 discussed the general lack of staff confidence and a desire for more evident leadership.

Recent staff meeting notes reflect a focus on completing the admission paperwork fully and correctly, following an identified safeguarding incident involving incorrect medication administration authorisation. Staff told us they knew what incidents to report and how to report them using the RMS and understood the duty of candour and were open and transparent with patients and families when things went wrong. Clinicians led the debriefing of patients and told us this was useful therapeutically. Following post-inspection high level feedback the trust launched work around ‘staff culture’ which included additional coaching by the physical intervention teams to improve staff understanding and confidence with autism, although no date had been set for this.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The service’s referral and admission processes ensured that all essential information about the patient was received to determine if the patient’s needs could safely be met. Staff involved all the necessary healthcare and social care services to ensure patients had continuity of safe care, both within the service and post-discharge. Staff discussed inviting staff from new placements to the ward to shadow the patient's routine and take over prior to a patient's discharge. Staff also spoke of conducting training sessions for staff teams from new placements to ensure that they have the necessary skills to care for the patient once discharged.

Some staff said they were concerned about the speed of the last three patient admissions. The service is planning to review the Admissions Panel process more frequently in response to staff concerns.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Ninety-eight per cent of staff were trained in safeguarding for both adults and children to at least level 1. Staff knew how to make a safeguarding alert via the RMS and knew how to identify adults and children at risk of significant harm. Staff knew the named safeguarding leads for the ward. The safeguarding leads provide safeguarding supervisions for staff and we saw evidence that staff have sought advice from safeguarding leads for advice. Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act. Staff followed safe procedures for children visiting the service. Staff told us they are notified if a child is coming and use a family room downstairs which was off the ward.

We scored the service as 3. The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. Staff assessed and managed risks to patients and themselves well and followed best practice in anticipating, de-escalating and managing challenging behaviour. Staff used restraint and seclusion only after attempts at de-escalation had failed. The ward staff participated in the provider’s reducing restrictive practice programme and service data confirmed that instances of rapid tranquilisation, seclusion and long-term segregation are reducing. The service provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We looked at 4 risk assessments and 4 risk management plans during the inspection. We found some evidence that patient preferences with respect to distance and space for privacy purposes had been recorded. We saw guidance written into risk management plans for staff “not tell the patient to stop”, and guidance for staff on individual patients’ preferences for distraction. We also saw guidance for staff on when to intervene physically to prevent self-harm by patients.

We saw evidence that risk assessments helped to formulate the patient risk management plans and that these plans had involved multidisciplinary team review. We saw individual preferences recorded in care plans based on individual risk with respect to observation levels and use of metal or plastic cutlery on the ward. Staff had made adjustments on a case-by-case basis. For example, evening visiting arrangements were adjusted for one patient and different kinds of support were provided for community leave.

The service maintained incident logs that included the number of incidences of restraint, rapid tranquilisation and use of seclusion and long-term segregation since opening in August 2025. There had been 68 instances of physical restraint. None of these instances involved prone restraint. There had been 5 instances of rapid tranquilisation since August 2025 that had all been fully documented. There had been 3 incidents of seclusion, which occurred in September 2025, January 2026 and February 2026. We saw evidence that all incidents had been documented on the RMS, reviewed by MDT, with recommendations recorded that included safeguarding referrals, increased observations, physical health assessments and updated care plans and personal support plans.

We did not see documented evidence in patient’s care records that staff had communicated with patients so that they understood their care and treatment. However, patients had access to an easy read copy of their care plan and we saw that staff had ensured that every patient had been offered access to advocacy and that referrals to advocacy had been made, including advocacy through family.

We scored the service as 4. The evidence showed an exceptional standard. The service was fully aware of all potential risks in the care environment and controlled them well. They made sure equipment, facilities and technology supported the delivery of safe care.

Staff did regular risk assessments of the care environment. Patient bedrooms and bathrooms, medicines room were checked and up to date. Equipment safety and cleaning records were up to date including daily fridge temperature records and a legionella control record. Ward layout allowed staff to observe all parts of ward. Staff had easy access to alarms and patients had easy access to nurse call systems.

The environment was clean and tidy with all fixtures and fittings new and in good condition. The clinic rooms were secure when not in use and were clean and with adequate space for medicines preparation and handwashing facilities. Access for nursing staff was via fingerprint keyless entry with secure codes back up. Room temperatures were monitored and documented. All equipment was maintained and calibrated and the calibration register had been updated. Ligature cutters were available in known locations. The fire safety risk assessment and annual maintenance check of the fire alarm system had been completed and was in date. Monthly checks of fire panel and visual inspection of fire extinguishers and fire doors are occurring and documented. Alarm tests took place weekly and were documented.

The building was co-designed by people with lived experience, led by a specialist architect who followed national good practice standards for therapeutic environments. The building incorporated autistic experts' advice about the colour scheme, appliances, fixtures and fittings and the design of the kitchenettes. The ward's lighting and acoustics were adapted to meet people's sensory needs. For example, all lights were dimmable, sound proofing panels were in place and wood finishes were incorporated based on recent research about people's feedback.

The alarm system sounded with a voice describing the emergency and location rather than a high-pitched alarm. Instead of sharp edges to corridors, curved walls and arcs were used to support the flow of movement. Kitchenette's included appliances such as fridges with no humming noises to minimise sensory overload. Kitchenettes were accessible to increase opportunities for independent choice and control and followed the least restrictive principle. For instance, if a person's risk assessment deemed boiling water was a hazard, then this feature could be disabled without affecting access to the rest of the kitchenette.

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

The service used the Universal Needs Based Resource Assessment (UNBRA) staff resourcing assessment tool to calculate the minimum staff numbers required as 14 during the day,14 during the afternoon and 10 staff at night. 2 nurses were required on every shift.

The staffing data indicated a current vacancy rate of 22.19%. Monthly staffing returns confirmed vacancies had been steadily rising since the service first opened in August 2025. Vacancies plateaued above the 20% level in February 2026. Average turnover at the service was 5.73% and sickness absence was 8.1% for the last 6 months, which is higher than the national NHS average sickness absence rate of 5.4% (Source: NHS Sickness Absence Rates, February 2026, Published May 2026). Staff told us “key people keep going off sick” and wondered how so many “people can be off sick from October to March without replacement.”

At the time of inspection, the service was short 13 health care assistants (HCAs) (representing 33% of the requirement), 8 nurses (representing 62%of the requirement) and 1.7 whole time equivalent (WTE) occupational therapists (representing 34% of the requirement). The service also had vacancies for a speciality doctor and for 33% of business administration staff. The original workforce model proposed 1 WTE consultant nurse and a 0.5 WTE associate specialist in intellectual disabilities, but this money was used to appoint a single Multi-Professional Approved Clinicians (MPAC) who was in post, but was absent due to sickness. Acknowledging the turnover and sickness rate at the time, an action plan was in place to bring bank and agency staff to fill shifts, with support of MDT staff in line with trust safer staffing policy.

Though required shift numbers were technically maintained staff told us teams on any given day were often new, inexperienced and unfamiliar with the patients and the MDT had been called upon quite consistently to assist in all aspects of routine care. The service provided evidence that block agency bookings of HCAs and bank nursing staff were used to maintain the required staffing levels. 783 shifts were covered by bank and agency staff between 1 September 2025 and 28 February 2026 with a further 320 shifts unfilled during this period. When agency and bank nursing staff were used, those staff were not always punctual because of their reliance on irregular public transport to get to work, especially on weekends and often required individual and repeated handovers. Staff described mornings as “quite tight” with several handovers required to cover staff arriving to shifts irregularly.

Gaps in leadership and clinical cover were impacting on staff decision making, roles and responsibilities particularly for bank, agency and new staff. We were told that recruitment was underway to fill nurse and health care assistant vacancies. The service manager had been absent for prolonged periods of time since August 2025. Psychiatrist input was also limited with 0.5 WTE for the service. Recruitment was underway for additional posts.

Staff also told us “there was no plan for who takes over” when the consultant psychiatrist or service manager was not there. Staff told us that this has led to clinical and physical health monitoring tasks not being reliably completed or delayed at the service, MDT inconsistencies, limited challenge of clinical decisions and poor coordination. For example, staff provided an example of an instruction to “get someone’s blood sugar” simply getting lost. Pharmacy staff offered challenge to prescribing decisions and individual clinicians to mitigate these risks despite system gaps.

Staff told us that due to the service manager being absent for prolonged periods there was a service-wide gap in role modelling, a lack of coordination of the service and a lack of regular checks and audits. Staff told us when incidents happened there was no one above the group of Band 7 nurses to coordinate the response as a service, creating a stressful work environment, contributing to high levels of staff sickness, anxiety and absence.

In addition to high levels of sickness absence among support workers and service management, the service also had unfilled roles in physical health, occupational health, positive behavioural support and occupational therapy. Staff told us ward activities and training had been cancelled to pull people back on the ward, in line with trust escalation policy. RMS training was postponed in February due to staffing shortages on the wards. The incident log for 22 February 2026 shows the nurse was unable to take her break to ensure that HCAs could take theirs.

Most staff had completed appropriate mandatory training in infection control, safeguarding (both adults and children), Mental Capacity Act, health and safety, clinical risk and conflict resolution. The training matrix showed 82% of staff had completed moving and handling training and 89% had completed restraint training at the time of the inspection. The service had scheduled additional face to face breakaway and physical intervention training by the physical intervention team based at Prentice, to address this gap.

Staff supervision levels reflected the current staffing pressures. Staff told us low staff numbers meant “care giving is prioritised over paperwork”. Most incidents received informal debriefs and check- ins at the time they occurred, usually with team leads who were on duty at that time. Medicines errors were addressed more formally through supervision with written reflections. The psychology team had begun offering one to one sessions for staff (4hrs a week) to cover the supervision gap and the psychologist had been providing one to one support for a nurse for 2 months following an incident.

Out of hours (OOH) medical cover was subject to delays caused by distance and lack of staff. There were nurses skilled in telephone triage based in Exeter, but the Trust employed only 1 OOH doctor for the whole county. If that doctor was already dealing with an incident, or in another part of the county, delays could be substantial. The service did experience an incident where the OOH doctor was not available to answer a query about medication intervals, delaying the response until the following day, without adverse effect in this case.

Following high level feedback given at the inspection, the trust confirmed the Service Director for Specialist Services now based herself at the location 2 days per week and a new senior nurse manager had been appointed to strengthen leadership and directly oversee the service. The new ward manager position is currently being advertised.

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Staff maintained equipment well and kept it clean. All ward areas were clean, had good furnishings and were well-maintained. Cleaning records were up to date and demonstrated that the ward areas were cleaned regularly. Staff adhered to infection control principles, including handwashing.

We scored the service as 2. The evidence showed strong controls for controlled drugs, emergency medicines and storage security. Medicines were stored securely in a computer controlled automated dispensing cabinet with fingerprint access. Controlled drugs were stored in a wall-fixed cupboard with nurse only access and a documented running balance. Controlled drugs were audited weekly and emergency medicines and equipment were checked and logged electronically every day with monthly reports generated. Medicine fridge temperatures were automatically logged. Oxygen cylinders were in-date with signage. Waste disposal, sharps bins and controlled drug destruction kits were all available.

However, there was limited evidence of formal expiry-check records and excess stock was identified during the inspection. ‘Date of opening’ documentation was missing on certain short-life medicines including eye drops and emollients.

Staff reviewed the effects of medication on patients’ physical health in line with NICE guidance, albeit subject to staffing shortages discussed above. When patients lacked capacity around medicines, staff made specific decisions in patient’s best interests which were documented in care records.

Following high level feedback given at the inspection, the chief nursing officer initiated a fortnightly Executive led oversight meeting to monitor the action plan to support improvement in stock audits and date of opening documentation.