Devon Partnership NHS Trust

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• 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

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.

This is the first assessment for this newly registered service. This key question has been rated requires improvement. This meant the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

This service scored 43 (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 1. The evidence showed significant shortfalls. The service did have a culture based on transparency, equity, equality and human rights, diversity and inclusion, however due to lack of leadership the execution of this was challenging. The service manager was often absent through sickness. The Band 7 nurses organised in teams around individual patients were unsure of their authority with respect to whole of service issues on a day-to-day basis. The absence and lack of visibility of service leadership severely inhibited the strategy and culture of the organisation and operational gaps had developed as a result.

This placed staff and patients at increased risk of harm as evidenced by the number of increased assaults on staff and other patients on the ward during September and October 2025 and January and February 2026. After one incident, a patient with insomnia was allowed by staff to vape on the ward at night, contrary to mutually agreed restrictions, because staff felt unsafe.

Staff told us the risk of being verbally and physically assaulted by patients was to be expected and was being managed without documentation. The responsible clinician stated he had never been to a team debriefs for any serious incidents. Another staff member, who was assaulted by a patient stated he wasn’t debriefed until three weeks after the incident. Staff felt the original model for the service, which included MDT review prior to acceptance of admissions had been abandoned with 3 admissions in the last month without MDT input, including a patient without a diagnosed mental health condition. Staff felt there was no clear direction for the current patient group.

In February 2026 the service’s responsible clinician had whistle blown on his own service to both CQC and the trust. The trust had responded to the concerns raised by the responsible clinician before CQC’s inspection by ensuring the Service Director for the Specialist Directorate was based at times throughout the week on the unit, and had appointed an interim senior nurse manager while a permanent ward manager was recruited. The trust had applied to the ICB to pause the admission of new patients and this had been granted, and the trust’s Chief Nursing Officer had initiated a fortnightly executive-led oversight meeting which monitored and had oversight of the service improvement plan.

We scored the service as 1. The evidence showed significant shortfalls. The frequent and prolonged absence of the inaugural service manager and other senior staff had severely limited the ability of service leadership to model appropriate workforce values and culture.

Since opening the service, the service manager had been absent approximately 50% of the time. The responsible clinician cover, planned to be 1.5 whole time equivalent (WTE), based on the number of patients at the service, consisted of 1 psychiatrist at 0.5 WTE and 1 multi-professional approvedclinician (MPAC) at 0.5WTE. At the time of the inspection, the MPAC was absent through sickness, and the consultant psychiatrist worked only 2 days per week at the service. Anything that can’t wait up to 5 days for the consultant’s next working day is referred to the on-call consultant in Exeter, things like section 17 leave approval for example. Responsible clinician cover has been provided by other learning disability consultantsfrom other parts of the trust, but their focus, as temporary clinical cover, has been 'what must be provided clinically that day', and not what should be done for the patient long term and not in consultation with the MDT.

Due to lack of leadership, the day to day running of the service has fallen to the nurses and Allied Health Professionals. The service has organised the nursing staff into teams around each patient. Each team is led by a nurse. The nurses who lead these teams have tried to cover senior leadership absence, but told us they were unsure of their decision-making authority with respect to what other team leads of the same grade are doing, let alone other allied health professions or service wide issues requiring a decision that day.

Staff told us they felt the absence of leadership had limited management “role modelling”, leading to skills erosion, stress and even cancellation of training. Many experienced staff had left the service since its opening and few staff expressed a desire to remain at the service in its current configuration.

Following high level feedback provided during the inspection, the trust advised the Service Director for Specialist Directorate was now based at the unit at times throughout the week with an interim senior nurse manager in post while a permanent ward manager was recruited. The ICB had paused the admission of new patients to the service and the trust’s Chief Nursing Officer had initiated a fortnightly executive-led oversight meeting which monitored and had oversight of the service improvement plan developed.

We scored the service as 2. The evidence showed some shortfalls. People did not always feel they could speak up and that their voice would be heard.

The service followed the triangle for care model. Patients and carers had opportunities to give feedback on the service they received in a manner that reflected their individual needs. The service has a freedom to speak up guardian, a ‘family and friends’ survey and provided information about freedom to speak up and making complaints in easy read versions for patients and carers. Staff supported carers and relatives to visit the service.

The service was trying to facilitate parent forums and peer support meetings for relatives. Uptake from families had been variable. All phone calls to relatives for feedback was logged on an electronic system. Staff could read the feedback given by patients and carers and also hear feedback from families through supervision and attending MDT. The service had planned a carers’ audit, to document how many times families and carers had contacted the service and the issues raised in the first six months of the service. However, one staff member told us this had not been done, due to lack of staff capacity. Staff stated that staff meetings did not happen regularly for the same reason.

The trust’s Freedom to Speak Up (FTSU) Guardians made promotional visits to the service to raise awareness of the service, offer engagement with staff within the workplace, and share information on a positive speaking up culture. An introduction to FTSU was part of staff induction. The quotes and reported incidents of staff speaking up included in the trust’s FTSU Biannual Quality and Outcomes Committee report of 16 December 2025 were not disaggregated, so could not be attributed to staff at this service. The report did however state that trust-wide “there has been an increase in the number of staff reporting a fear of reprisal if they speak up – 18.67% in this period, against 14.05% at the end of 2024/2025, and this includes the fear of losing their job.” Staff at this service told us they felt “scared to speak up” and if they did speak up to their immediate seniors in the absence of senior management, they had not received a response or feedback.

Following the inspection, the trust informed us that staff from The Brook told the quarterly Freedom to Speak Up meeting conducted on 19 March 2026 that “ they felt a lot safer with the newly appointed interim senior nurse manager being present and it is feeling that everything is moving in a positive direction at this moment.”

We scored the service as 2. The evidence showed some shortfalls. The service did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who work for them.

There were equality and diversity champions within the service at both nurse and health care assistant level, but staff told us the service was “chaotic at the top” with “senior leaders not there at the same time” and a “lack of deputising and ownership” meant “no one was picking things up”. Some initiatives had been progressed by pockets of excellent individual leadership, particularly by referrals and sign posting for staff by the service psychologist who had personally recognised neurodivergence in several staff members.

Following high level feedback provided during the inspection the trust had appointed an interim senior nurse manager while a permanent ward manager was recruited into and had implemented a service improvement plan which was under fortnightly review.

We scored the service as 1. The evidence showed significant shortfalls. The service did not have clear lines of responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The prolonged sickness absence of the full-time service manager without cover and only 2 days responsible clinician cover per week at the service since inception meant the service was not well-led, despite pockets of excellent individual leadership among staff. In the absence of senior leadership, staff told us there has been a “lack of deputising and ownership” of actions with the result that “no one is picking things up”. The service manager was absent from the service during our inspection, and the senior clinician was present only on the first day of our inspection due to their working pattern.

The senior clinician told us there was no clear framework of what must be discussed at service level to ensure that essential information, such as learning from incidents and complaints, was shared and discussed at the service. Staff told us families say they don’t feel listened to. Nurses responsible for patients were not aligned with their families and the families’ questions went unanswered. MDTs were taken up by family questions about the patient’s next leave, which could have been handled in daily meetings, and not enough time was being spent in MDTs discussing patient presentation and what the service was doing for each patient. The timing and frequency of MDTs was still being debated at the service six months after opening.

We saw an MDT chaired by a Band 6 occupational therapist in the absence of any clinical leaders. Another staff member told us they been asked to provide leadership cover, without adequate experience to do so. We saw that actions decided at an MDT on day 1 of the inspection had not appeared in the patient’s care plan by the end of day 2 of the inspection. Staff told us this was because no one owned the various MDT actions or had responsibility to oversee such actions were completed. Staff told us, the ad hoc chairing of MDTs by whoever was available on the day generated MDTs that “lack of constructive challenge and weak governance”.

Staff provided one example, confirmed by our review of service incident records, of a prolonged period of difficulty with one patient being managed in the absence of a seclusion room at the service. Staff escalated their concerns and made requests for the physical intervention team to assist through their immediate line managers. These requests were escalated but ultimately unanswered. Staff described other situations with patients where no one with sufficient authority was present in the service to say “this is what we are doing to do…” about certain individual patients or situations on any particular day. Multiple staff told us they felt patients and themselves were operating “in limbo” and staff had gone off sick with stress or left the service altogether as a result.

There was limited evidence of that audits of care records were being completed in a routine way by the service. One staff member described a planned carers audit to track how many times carers had contacted the service and to ask whether carers wanted calls and how often. This audit had not been started since opening, despite several reschedules due to insufficient time. Other staff told us they “have all the standard trust audits, but it has been quite difficult to have the time to do it because there has been a lot of gaps in the support structure”.

Some staff told us they had not completed any audits since the service opened, or they had intended to complete certain allocated audits, of patients’ physical health for example, but had not done so for lack of capacity to deliver both daily care to patients, line management of staff and service management functions. Some support staff told us they did not have access to the electronic platforms that contained patient care records because of an incomplete allocation of iPads at the service and relied exclusively on information at supplied at handovers.

We reviewed one incident where a staff member noticed a patient’s written discharge summary from an acute hospital and the associated medicine were both missing from the patient’s care record. This was noticed through individual action and not through routine review. When the required medicine was received after several day’s further delay, a further dose of medication was missed “due to the on-call day to night handover missing this information due to an oversight and the bank and agency nurse not handing this over to the day staff”. Following the inspection the trust has informed us informed us that all care plans and risk assessments were reviewed and updated and all medical care advice is now included in every shift handover. Following post inspection feedback, we were told that interim measures have taken place to strengthen visibility of leadership whilst recruitment was underway.

We scored the service as 3. The evidence showed a good standard. The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

Staff described working relationships positively, but noted many pressures in the wider social care system which contribute to delayed discharges and difficulties in discharge planning beyond the service’s control. Devon County Council approved £22 million pounds worth of budget savings in 2025-2026, which is primarily delivered through the Council’s largest spend area of adult social care. The cuts to council staff and services have directly affected critical discharge pathways and discharge capacity, particularly through fewer social workers and care coordinators and reduced commissioning capacity for care packages

Directorate leaders engaged with external commissioners who visited the service every 8 weeks. Care and treatment reviews were part of these visits, but patients and staff had not met with commissioners to give feedback. The service had been trying to set up ‘Feedback Friday’ meetings for patients, but staff told us this has been quite difficult due to staff prioritising observations.

We scored the service as 2. The evidence showed some shortfalls. The service focus on scenario-based staff training , continuous learning, innovation and improvement at the service had not translated into improved staff confidence. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

The service was participating in several centrally registered quality improvement (QI) and national accreditation projects. The physical health clinical lead had completed a two-month quality improvement project in March 2026 on alternative injection sites for rapid tranquilisation that are less traumatic for the patient.

The clinical lead has run 2 projects. The first of these was a training initiative that simulated 10 patient scenarios likely to take place at the new service. These scenarios were also filmed as a teaching resource. This scenario based training was delivered to staff being inducted into the new service 2 weeks prior to the service opening. The majority of health care assistants that finished this training have left the service and remaining staff told us throughout the inspection that they did not feel equipped or confident to engage with or safely care for patients. Staff told us quality improvement “means different things to different people at the service, especially HCAs, who feel it doesn't apply to them”.

The second quality improvement project was a data collection project to monitor and map incidents of racism, the barriers to reporting incidents, whether certain measures can increase reporting and feedback actions taken in response to incidents. The project had generated a heat map, that we saw during the inspection, of what, where and who is involved in each incident at the service, and potentially where under-reporting of incidents may be happening.

Quality improvement leads at the service were aware of research organisations like the Leicester Learning Disability Register and Cornwall Intellectual Disability Equitable Research (CIDER) partnership, but was not listed publicly as a member, contributor or recipient of research funds on either body’s website. The quality improvement clinical lead advised that the service was working towards accreditation with the Royal College of Psychiatrists’ Quality Network for Learning Disability (QNLD) programme.