We conducted this follow up inspection because we found improvements were needed during our scheduled inspection on 3 - 7 February 2014. The Trust had sent us an action plan informing us how they would make improvements in order to be compliant with; Regulation 14 of the health and social care act 2008 (regulated activities) regulations 2010 meeting nutritional needs.

We visited three inpatient areas on the hospital site, spoke with a variety of staff and spoke to six of the patients on the wards. We were provided with an internal audit report completed by Audit South West who are part of a group of NHS internal audit providers. This had detailed all the actions which the Trust had taken following the previous CQC inspection. At this inspection and after reviewing all the information we had gathered, we found the Trust had made sufficient improvements to meet the compliance action.

This visit was carried out on Thursday 19 April by two compliance inspectors.

Everyone we spoke with said that they thought that their privacy was respected and that they were treated with dignity. We observed that staff interacted with people in a friendly manner and continually offered choices to people.

One person said “Even though I don’t want to be here, they’re still good to me. They’re good to all of us”. Another person told us that “Things have improved lately. It’s great that the doors are left open for longer in the evenings now”. When asked if they were asked to be involved in making choices and decisions one person told us “I am always being asked to look at my care plans; I get fed up with it sometimes, but it’s good really”.

People we spoke with told us that staff provide them with information about their care and treatment and make sure that people give consent before and treatment is carried out.

All of the people we spoke with knew that they had care plans and said that they received the care that they needed. People confirmed that arrangements were made for them to see health and social care professionals according to their individual needs.

A member of the inspection team asked a patient about the food. They replied, “It’s half and half, sometimes it’s good sometimes not so – we get rice about three times a week and it’s a bit dry!” They went on to explain that they get a menu at the beginning of the week and they have a choice. Another patient spoke with the same team member and said, “the food is terrible here, I buy my own and bring it in’. From other evidence seen patients are supported to shop locally for some items of food they like and staff will help them to prepare it. All patients have their own lockable food storage cupboards that they can access as they wish. This supports and promotes independence.

Owen House has a member of staff that is responsible for organising sports and leisure. When speaking to a member of the team they explained they arrange activities like attending the gym, cycling and walking. They explained that during the evening they organise competitions in the games room and this appears to calm patients down. The sports coordinator was clear about their approach saying that they will encourage patients to take part, but no more than that.

Through examining patients’ daily progress notes and from our conversations with them it was clear that they are involved in a range of these activities.

As part of our inspection of Owen House we asked the ward manager to supply us with the contact details of patients’ relatives. We attempted to contact all of the people on the list, three patients’ relatives spoke with us. Their comments about the service were positive; they spoke about patients being treated with respect, being treated well, good communication from the service about their relatives needs and progress, the nursing staff being very good and people being safe.

Langdon Hospital is an NHS forensic hospital based in Dawlish in Devon and run by Devon Partnership NHS Trust.

We inspected the Dewnans Centre which has four medium secure wards with a total of 60 beds. The four wards are Ashcombe, Holcombe, Warren and Cofton. The Dewnans Centre supports people on a treatment pathway from acute forensic emergency admissions through to longer-term medium secure services and step down care as people's health and wellbeing improves. Ashcombe is an admissions assessment ward providing care to people with acute mental health conditions. Holcombe Ward is a treatment ward for people with complex mental health needs, including people with personality disorders. Warren and Cofton provide services to people whose mental health is stable with the care and treatment provided by the hospital. People can and have moved to low secure services from these wards.

We visited Avon House, a 14-bed longer stay low secure ward; Chichester House, a 15-bed shorter stay low secure ward; Owen House, a 16-bed open ward for men with complex mental health needs and Connelly house, a 6-bed rehabilitation unit.     

There were many positive aspects to the care provided to people using the services at Langdon Hospital. Physical health assessments had been carried out and reviewed for all patients. Where appropriate, physical health needs were addressed as part of the patient’s care plan. Patients had good access to primary health care.

Improvements had been made in care planning since our last visit. Care plans were comprehensive and specific to the needs of the patient, with the patient involved in their development. Care plans were re-evaluated and updated regularly. Plans to discharge the patient or move them towards less secure environments were included as part of the care planning process.

Robust arrangements were in place to ensure that leave under section 17 of the Mental Health Act was appropriate and authorised. Risk assessments were consistently completed for patients. Case records demonstrated that comprehensive risk assessments were completed, regularly reviewed and updated when needs or risks changed. These assessments were reflected in the care plans with measures identified to manage or mitigate the risks.

All patients were legally detained under the Mental Health Act 1983. All treatment had been given under an appropriate legal authority. Patients were informed of their rights under the Mental Health Act 1983 and were supported in exercising those rights.

Improvements had been made to the seclusion facilities in the Dewnans Centre since our last visit. Improvements were needed in the seclusion environments in Avon House.

Records were completed for incidents of seclusion but there was no seclusion log or register and so it was not possible to check that all incidents of seclusion had been recorded appropriately. Incidents of seclusion are reviewed locally by Ward Managers and Senior Nurses both at team and directorate level. The current recording does not ensure all the necessary details are available to enable effective monitoring of trends on a trust wide level.

Out of hours there were some delays in patients in seclusion being reviewed by a doctor. This was because the on-call doctor covered several inpatient sites which affected their availability.

We found incidents of patients being nursed in, and prevented from leaving, the extra care areas of Avon House and Chichester House. Whilst staff were in the room with the patients, as they were unable to leave this is seclusion. These had not been recorded as seclusion episodes by staff and there was a lack of clarity from some staff as to the definition of seclusion.

Staff found it hard to describe clearly the areas for improvement and action taking place at Langdon Hospital. There were a range of governance measures in place including the audit processes, meetings relating to governance processes and improvement plans, but these need to become embedded so they are meaningful to staff working in the hospital.