We carried out a responsive inspection of Wonford House Hospital. We were notified in October 2013 about a serious untoward incident by the Trust, which was being investigated. The main purpose of the visit was to establish whether patients were safe and to look at how they were being cared for, risk management, consent and staff skills and training.

During this visit, we spoke with 10 out of 39 patients in depth about their experiences on Delderfield and Coombehaven wards at the Cedars Unit and also spoke with three visitors. We spoke with 20 out of 31 staff who were on duty at the unit, which included consultant psychiatrists, doctors and nurses. At the end of the day, we also spoke with a group of senior managers, which included two executive directors.

Patients told us the staff were mostly “Very caring” and “Always available to talk to”. Patients said they felt safe with comments like “They have been checking on me, offering one to one time and making sure I’m safe”. Manager’s and patients told us about the introduction of dedicated protected time for staff to meet with patients, which most saw as a positive step forward. For example, one patient said they were having “plenty of one to ones to talk about how I’m feeling”. However, patients said this sometimes clashed with activities they were doing so wasn’t the best time of day. All the staff told us this was being looked at with the involvement of patients who had used the services.

Staff were receiving training and support. The majority of staff told us they were enjoying working at the unit, with comments like “I came here to gain new experience and haven’t been disappointed. The support systems are excellent”.

The trust told us in September 2013 a quality and safety review had been done. This showed the trust had taken action to reduce potential risks to patient safety following identification of concerning patterns and themes. Bed numbers at the Cedars Unit had been reduced and further changes to the service were planned following the trust’s quality and safety reviews. We found this was a safe service and patients were mostly well cared for. Our discussions with patients highlighted there were some areas for improvement around greater involvement in care planning, including discharge and information and practices around patient’s rights. The named keyworker role required greater consistency in the way it was managed and be clear enough for patients to know they could talk with staff as agreed in their care plans. The trust was non compliant in one of the three essential quality and safety standards we looked at.

We carried out this responsive review in response to concerning information from two investigations. The Health and Social Care Advisory Service (HASCAS) looked into events leading to four homicides in the community in 2007 and produced a number of recommendations. A serious untoward investigation carried out by Devon Partnership NHS Trust looked at events leading to three serious incidents on the Cedars Unit between February and May 2011.

We carried out a responsive review of Wonford House Hospital. This included an unannounced inspection of Coombe haven, Cedars Unit on 1 and 2 November 2011, and because of the concerns we looked the key outcomes 1, 4, 7, 10, 14 and 16. We observed how people were being cared for, talked to four people in depth who use services and nine care workers. We checked the provider’s records and looked at records of four people who use services.

Ninety seven community teams across Devon come under the location of Wonford House Hospital and we sampled these services as part of this review. We looked at outcomes 1, 4, 6, 7,14 and 16. Through the patient experience team, we held three ‘Meet the CQC meetings’ in Barnstaple, Exeter and Torquay. We met 11 people and four carers on 8 and 10 November 2011 and asked them for feedback about their experiences. We also carried out telephone interviews with four people and/or their carers during November 2011 who receive support to hear about their experiences with the trust. We contacted 16 care workers during November 2011 across Devon providing a range of services and conducted interviews with them.

We wrote to the provider to ask for information about progress made with action plans the trust has in place and also risks that have been identified and how these are being addressed. In addition to this, we were sent information demonstrating how the trust is engaging with people and encouraging their involvement in development of services.

We sought information from local intelligence sources. These include:

• Local Intelligence Network (LINKs) – this gave us feedback about community services.

• Devon County Council Health and Adults Services Scrutiny Committee – earlier this year this gave us feedback about the progress the Trust has reported it is making concerning the improvement of services for older people.

• Mental Health Commissioner feed back summary – this gave us feedback about Coombehaven, which was visited in November 2011.

• Patient Experience Team – this gave us feedback about network action groups and carer meetings that had taken place across the trust.

• Be Involved Devon (BID) – this gave us examples of user involvement in the trust.

Some of this information is pertinent to this location and is referred to where appropriate in this report.

A Mental Health Act Commissioner visited Coombehaven in November at Wonford House Hospital to meet those patients detained under the Mental Health Act 1983. These visits are to ensure that people’s rights under the Act are being properly safeguarded and that the Mental Health Act 1983 and its Code of Practice is being applied correctly. During the course of their visits the Mental Health Act Commissioner made observations and recommendations that assist the CQC in its determination of the trust's compliance with the relevant regulatory outcomes of the Health and Social Care Act. Overall, the trust has provided a satisfactory response to previous visit recommendations. Further recommendations have been made

People using both inpatient and community services are generally satisfied with the support they receive. They have told us that they feel safe and know who to contact for support when in crisis. Similarly, they are confident that their mental health worker recognises when they are at risk and takes appropriate action to protect them. There are two areas that people tell us need improvement, both of which relate to inpatient care. Engagement with people on the ward needs to be more proactive because people tell us that they can find it difficult to do this when they are feeling vulnerable. People also tell us that they sometimes experience boredom and need more activities to relieve this. They have told us about some good experiences of these, but the ward team needs to build on these further. People feel listened to and the trust is constantly working towards improving their experiences.

Under each outcome the report is divided into two headings - inpatient ward and community services – so that there is a clear distinction showing the inpatient and community experiences of people using services run from the Wonford House Hospital location.

Community services

Devon Partnership NHS Trust has around 100 community teams. We visited a number of community teams including crisis teams in Exeter, North Devon, Torbay, East and mid Devon and Teignbridge. These teams provided care and support for people living in the community with mental health needs. The teams we visited were Liaison, Assessment and Outreach, Older People’s care, Personality Disorder, Wellbeing and Access, Recovery and Independent Living, the Eating Disorders team and the Learning Disability team. We also visited a Clozaril medication administration community clinic, and the older people’s community clinic in Teignbridge.

We found areas of good and excellent practice and many positive interventions across the wide spread of teams we inspected. The community services for older people, and for learning disabilities were outstanding. People told us they felt well-supported and described staff as hard working and committed to patient welfare. People who used the service could clearly describe a recovery approach to the care and support they received that was responsive and personalised to their needs. One person said “I could not do without my support worker; she is always there for me, even when I text her frequently. I know she is busy, but she is always calm and helpful to me”.

The community and crisis teams were well-led at a local level, although some staff felt that senior staff were disengaged with the day-to-day delivery of the service. Staff morale was generally high, although there was a loss of confidence in some teams as they are currently undergoing a service redesign and are not yet sure of how they will fit into this.

There were three main areas where improvements need to be made. These all affect the responsiveness of the services which could present a risk to people needing care and support.

Out of hours support to patients – at night the only crisis team response is an “out of hours” nurse practitioner who has a wide range of roles. Patients and carers have no effective way of contacting this practitioner directly. When they are away from their office (which they often are) the caller has to leave a message on an answer phone which might not be picked up until the crisis team start in the morning.

Patients, including those who have previously presented to the crisis teams, were being held and risk assessed by staff in community mental health teams while waiting, in some cases for several months, to be allocated to a recovery team care co-ordinator. This means that whilst individual cases are prioritized and their safety is being monitored, they are not getting the treatment and support they need.

Access to psychological therapies – the trust had a large waiting list for step 4 psychological therapies (over 700 people in Exeter, over 200 people in Torbay and over 100 in North Devon). This has an adverse effect on care and treatment. The Trust has implemented a new two-tier approach to the provision of psychological therapies but this has not been applied consistently across the trust.

Hospital services

Wonford House Hospital is in Exeter. Devon Partnership Trust have their head office at this site and also provide a number of services. We inspected the acute in-patient services which are provided on two wards Delderfield and Coombehaven. These two wards are called the Cedars Unit. This service is for people from Exeter, mid and East Devon but often patients are using the service from other parts of Devon. Also based at this hospital is The Haldon which is an inpatient eating disorder service which also accepts patients from across Devon and from other counties.

We found that The Haldon Eating Disorder Service provided an effective, evidence-based treatment programme and a high standard of care for people with eating disorders. It was a safe and secure unit, where staff cared for people in the least restrictive way. We found that there were enough members of staff to care for people safely. People who use the service told us that they felt safely cared for.

A thorough assessment process ensured that people had a good understanding about the treatment options available and they were supported to decide if it is the right place for them. The assessment process allowed the staff and individuals to form an individualised care plan. Good-quality information was given to carers and individuals throughout their stay on the unit. The staff worked well with other professionals to meet the needs of people.

We found that The Haldon Eating Disorder Service was well-led. Staff told us that they had the training and support they needed for their roles. There was a positive and open culture within the staff team. The manager was able to show that incidents were recorded and investigated appropriately.

Patients admitted to both wards on the Cedars Unit felt safe. Risks were managed effectively but we were concerned that some responses to patient safety had resulted in ‘blanket rules’, in particular the restrictions around smoking and access to fresh air. We also found that risks regarding patients’ leave under section 17 of the Mental Health Act were not consistently recorded to show they were being managed.

On the Cedars Unit patients told us that the staff were friendly and helpful but the majority of people said that staff were often too busy to spend time with them; in particular nurses on the ward spent a lot of time in the ward office. A high number of patients did not know who their named nurse was or spend regular time speaking with them about their care which was an improvement that needed to take place from the previous inspection. The unit operated patient protected time from 10:30 to 11:30 but this was the time that most patients were off the ward at the activity centre.

People told us they got better on the unit but we found there was inadequate care planning for patients on both wards. On Coombehaven Ward we found two patients who did not have a care plan and 14 out of 17 patients across both units did not know if they had a care plan. Patients had not received a copy of their care plan and there was no record that they had been involved in its production. These were also areas for improvement from the previous inspection. Other patients did not have care plans that reflected their current physical healthcare needs and these needs were not always being met. However, patients had been involved in reviews of their care at ward rounds. Patients were able to discuss their medicines with their consultant and most patients were positive about their medical input. Our visit on 21 May 2014 found that required improvements in response to a warning notice had been made.

Patients received a good occupational therapy service. In addition to the activities centre there were therapy groups held on the ward that patients could attend. Occupational therapists also supported people to cook meals if they chose and were able to support people to go out.

We found there was good practice in medicines management. There was a good working relationship between members of the teams and also with other teams and providers.

On the Cedars there was a clear trust-wide governance system in place. Some routine quality audits to ensure the safety of patients had not been completed in line with the trust’s targets. An improvement plan from our last inspection said the work would be finished before this inspection, but this had not happened. This means the governance processes are not yet fully embedded at a local level. Leadership needs to improve to ensure a consistently high-quality service is provided to all the patients across both wards in the Cedars Unit.