- SERVICE PROVIDER
Devon Partnership NHS Trust
This is an organisation that runs the health and social care services we inspect
We served a warning notice on Devon Partnership NHS Trust on 5 June 2025 as the quality of health care provided needs significant improvements in Forensic inpatient or secure ward services at Langdon Hospital.
Assessment report published 21 November 2025
Contents
Ratings - Acute wards for adults of working age and psychiatric intensive care units
Our view of the service
We carried out a responsive onsite assessment following information of concern received from various external sources relating to patient safety and leadership. We undertook onsite visits between March and October 2024. We visited Haytor Ward, Salus Ward, Delderfield Ward, and The Junipers, to inspect the care being provided under the key questions Safe and Well-led. These key questions were rated good following our previous inspection in 2021.
We found the Trust had appropriate leadership structures in place and were working to address staffing issues within the service and adopted more aligned ways of working across the various wards. Staff kept patients safe and understood their roles and responsibilities. During the previous inspection, a breach of regulation was identified under regulation 12 (safe care and treatment) relating to ligature risk assessments. Staff have undertaken ligature risk management training and were able to explain understanding of known risks on the wards, this meant the previous breach of regulation 12 was now met.
However, we found that the Trust had not completed their own action plan to improve ligature risk assessments across the wards. Ligature risk assessments remained generic and not individual to the ward they related to. This meant staff unfamiliar with the wards would not know explicit mitigation for each identified ligature risk.
The Trust was issued a requirement notice under regulation 17 of the Health and Social Care Act 2008 (regulated activities).
Following this inspection, senior leaders took action to address this quickly and worked with other external organisations to improve their ligature risk management approach.
People's experience of this service
People we spoke with were positive and many expressed high regards for the staff’s compassion, empathy, and attentiveness. These qualities created a supportive and therapeutic environment, contributing significantly to people’s overall satisfaction with the care they received.
Consistent themes emerged in feedback, particularly around feelings of safety, respect, and involvement in their own care. People valued having dedicated time with their named nurse, they appreciated the encouragement to participate in ward rounds and their care reviews, where they could openly voice their opinions. Additionally, we were told that staff were proactive in managing individual risks to maintain a therapeutic environment, which people found reassuring.