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

During this inspection, we identified some potential barriers for the service to provide safe care. Some wards occasionally did not have enough nurses on duty, which impacted their ability to deliver safe and effective care.

However, staff demonstrated a strong understanding of ligature management and managing peoples’ individual risks. They minimised restrictive practices, managed medicines safely, and consistently reported safeguarding concerns.

Some wards still required minor estates work and redecoration to improve the environment for people using the service.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People using the service told us they felt safe. Both they and their carers received information about their care, with regular reviews of risks. They were aware of whom to approach with concerns and felt that staff listened to them.

Staff and leaders told us they received information from peers and leaders that informed their practice when learning had been identified.

Staff completed mandatory training and had access to additional courses of interest, this occasionally required sign off from their managers.

All staff had access to, and training on, an online incident reporting system where the reporter of an event received feedback following the review and closure of an incident.

Learning from incidents was fed back to the ward through staff huddles and team meetings. Additional information was cascaded to teams from the monthly learning from events forum. The incident reporting system had actions to implement as a result of learning from incidents.

There was a process to review referrals to ensure that only those who would benefit from the service were admitted.

Staff reported being aware of how to escalate health concerns, which helped to keep people safe. They highlighted their ability to liaise with partner agencies and health services to effectively address the needs of people using the service. Staff felt comfortable to discuss peoples risks and needs openly, fostering a transparent environment for care delivery and care planning.

Staff also shared that they had good working relationships with other wards, engaging in regular communication. Wards coordinated with each other about patient flow and any immediate issues. This collaboration helped maintain patient safety throughout.

As part of routine monitoring of the service, the integrated care board (ICB) had raised no concerns to the commission in relation to this quality statement.

Structured multi-disciplinary team meetings were held to openly discuss the treatment pathways of people who use the service, aiming to facilitate safe discharges and transitions to appropriate care.

People using the service told us they knew to speak to a nurse or staff member if they had any concerns. Everyone we spoke with said they felt safe on the wards.

Staff demonstrated a clear understanding of the safeguarding policies in place and had in-depth knowledge of safeguarding practices. All staff had completed mandatory safeguarding training, meaning they were well-equipped to identify and respond to safeguarding concerns.

They also had access to an online incident reporting system, which allowed them to report safeguarding concerns quickly and efficiently. This system could automatically generate referrals to both internal safeguarding teams and external agencies, such as the local authority and the Multi-Agency Safeguarding Hub (MASH), making sure that concerns are escalated appropriately and in a timely manner.

We observed safeguarding concerns being raised and discussed in relevant forums such as handover meetings.

Each clinical specialism had a safeguarding supervision group with monitored attendance to improve staff participation. An online incident reporting system was in place, enabling staff to promptly report safeguarding concerns. The Trust had a centralised safeguarding team. They attended the daily Quality, Safety, and Performance Huddle to contribute insights and provide a safeguarding perspective. The Trust generated a safeguarding bulletin to inform and update staff regularly. Every ward was required to have a safeguarding champion to promote best practices. Dedicated literature and resources had been designed for both people who use the service and staff to enhance understanding and awareness of safeguarding issues.

In the care records we reviewed, we saw that the voices of people using the service were clearly reflected, incorporating advanced directives, positive behavioural support plans, and 'My Future Support Plans.' This input contributed to person-centred care plans and risk assessments tailored to individuals' specific needs and preferences. People told us they were aware of their own risks and were included in discussions during ward rounds. Where appropriate, family members and designated carers were also given opportunities to participate in their relatives care decisions.

Everyone who worked at the service knew and understood the risks to people well. Staff told us risk assessments contained up to date information to support people safely and effectively. Staff had a good level of understanding when identifying potential risks, managing actual risks, and keeping these under review. Staff understood their responsibilities for reporting accidents, incidents, or concerns.

All care and treatment records we reviewed included individual risk assessments that were consistently updated to reflect changes in the person's needs and circumstances. Wards also utilised a range of tools, including Positive Behavioural Support (PBS) plans, seclusion safety tools, ‘My Future Support Plans’, preventing absent without leave (AWOL) assessments, and ‘Traffic Light System’ care plans. These tools helped to build a balanced and proportionate approach to risk management that supported people’s choices and respected their autonomy.

The Trust had established processes that provided real-time access to team-level and directorate-level data through online incident reporting system dashboards. Detailed monthly reports were also provided to the Directorate, facilitating local learning from experience. The Experience, Safety, and Risk Team held daily Incident Triage and Response Meetings, with outcomes recorded, prompting timely action and monitoring of events.

To further improve the quality of care records and effective risk management, the Trust had implemented two key audit programmes. The Quality Review of Clinical Records (QRCR) audit was conducted monthly across all teams. This audit supported the identification of risks to patient safety, health, and welfare, while also highlighting areas of excellence. It allowed teams to assess their compliance with care standards and identify areas for improvement.

The DPT Fundamentals Audit focused on the Care Quality Commissions (CQC) Fundamental Standards and was carried out across all inpatient wards. This audit gathered feedback from people that used the service, their carers, and staff to help build good care delivery. It also addressed risks and promoted continuous learning and development.

These audits helped keep care records accurate, up-to-date, and reflective of the care people received.

People reported feeling safe within the hospital. While they were unsure of specific fire procedures, they felt it was sensible to follow staff guidance in any emergency. Individuals expressed satisfaction with the amenities provided.

Staff reported that regular ward walk-arounds were conducted, with checklists used to audit the environment and equipment. They confirmed that they could raise any concerns regarding the care environment with management and the estates team, who then reviewed and addressed the issues as necessary.

We conducted ward tours and environmental checks, including inspections of the clinic rooms. No concerns were identified regarding the safety of the environments, and equipment was found to be suitable for use.

However, environmental ligature risk assessments were generic and not available for staff to view on all wards. This meant staff unfamiliar with the ward, did not have access to specific information to inform their practice on keeping them safe from potential ligature incidents.

The Trust had implemented measures to enhance the safety of the wards by installing anti-ligature door sensor sets, and saloon doors in areas with en-suites. Additionally, the Trust’s Health and Safety Team had service level agreements with the Royal Devon University Hospital (RDUH) to manage and service all medical devices. The RDUH Resuscitation Team oversaw a web-based platform that supported efficient management of resuscitation medication, oxygen equipment, and Grab Bag safety checks, keeping them up to date.

People using the service expressed satisfaction with staffing, frequently noting the presence of a well-established core team.

Leaders reported that staffing levels on wards were satisfactory, with each ward adhering to NHS safer staffing guidelines. They noted that the Trust maintained a low vacancy rate and could easily support enhanced ward acuity using NHS Bank, or agency staff when required. However, feedback from staff indicated that there were occasional challenges in maintaining staffing levels and balancing clinical expertise across teams.

We observed that wards were adhering to safer staffing levels. Staffing teams were working cohesively and providing care in a manner which enabled staff to meet the needs of the people using the service.

The Trust had established effective recruitment practices to bring in safe and effective staffing. Vacancies were actively monitored, and recruitment channels were designed to attract a broad pool of candidates. The Trust had implemented a ‘Grow Your Own’ approach to recruitment, offering Apprenticeships and Nurse Associate opportunities. This approach had seen good uptake, leading to improved staff retention and a workforce familiar with Trust processes and the needs of people that used the service.

To maintain safe staffing levels, the Trust had implemented monitoring systems. A monthly Safe Staffing report was presented to the Board for assurances. On an operational level, daily Quality, Safety, and Performance Huddles were held to review staffing levels, enabling swift escalations, redeployments, or adjustments to balance risk and dependency across the inpatient system.

The Trust also provided staff with suitable training, supported by regular supervision. Staff compliance with these requirements was closely monitored to maintain a qualified and safe workforce.

People using the service reported that the hospital and wards were clean. However, they told us that some wards required redecoration due to looking unsightly with damaged walls.

Staff reported that infection prevention and control audits were in place and regularly conducted. They demonstrated a clear understanding of the importance of personal hygiene and infection prevention measures, highlighting their awareness of the basics and the role they play in maintaining a clean and safe environment for staff and people who use the service.

Staff were seen washing their hands and using PPE appropriately, and we were asked to use hand sanitising stations upon entry to the wards. The Infection Prevention and Control (IPC) team was present on one ward, conducting a safety check. We also observed domestic services staff actively carrying out cleaning activities.

The Trust's Infection Prevention and Control team conducted a Quarterly National Standards of Cleanliness Audit to embed compliance with national guidance. All staff members are responsible for maintaining the cleanliness of the wards, with cleaning checklists in place. Staff were required to complete mandatory training on infection prevention and control, equipping them to be able to reinforce best practices and uphold infection control standards.

People using the service told us they had no concerns with the medications they were taking. They knew what it was for, and it was reviewed at ward rounds.

Discussions with staff indicated confidence in using the digitised medication dispensing and administration systems. Staff could easily locate relevant policies and procedures and demonstrated clear understanding of clinic room monitoring and auditing processes, including knowledge of assigned responsibilities. They reported strong working relationships with the wider multidisciplinary team (MDT), which enhanced their understanding of the rationale behind specific medication prescriptions for individuals’ treatment.

Management, storage and administration of medicines was robust. We reviewed clinic rooms, including the medication stock and equipment, and completed a check of medication prescription charts. We found no concerns regarding clinic rooms, equipment, medication stock or medicines management.

Policies and processes were in place to assist in people receiving medicines safely and promptly, supported by a digital medicines administration record. Protocols for 'when required' (PRN) medicines were established, detailing guidance to help staff understand safe and effective use. Staff conducted regular stock checks, with audit records readily available. The clinic rooms were clean, orderly, and well-maintained through routine audits. They were equipped with an examination couch and appropriate equipment for conducting physical health checks, all of which were calibrated.