Care Quality Commission tells Devon Partnership NHS Trust that it must urgently improve the quality of some services

The Care Quality Commission (CQC) has told Devon Partnership NHS Trust that it must make urgent improvements to the quality of its medium forensic inpatient or secure wards.

Inspectors visited the Ashcombe ward and Holcombe ward, two of the medium secure wards at the Dewnans Centre at Langdon Hospital in Dawlish in August 2020.

This inspection was undertaken following information about the death of a patient and other safety concerns which had been reported to CQC.

As this is a focussed inspection it does not affect the ratings for the service.

CQC’s Head of Hospital Inspection Karen Bennett-Wilson, said:

“We completed an urgent inspection following the tragic death of a patient at Ashcombe ward. We found a number of concerns relating to patient safety and staffing levels and we told the trust to make immediate improvements.

“The trust must ensure that there are always sufficient numbers of suitably qualified, skilled and competent staff on wards at all times. In addition, it must ensure the environment is safe and that there are robust methods for staff to follow when carrying out observation of patients.

“Following our inspection, we informed the trust’s leadership team of our findings and told them that they needed to take immediate action to address the issues. The trust has made some urgent improvements and knows what it must do to ensure it continues the required improvements.

“We are continuing to monitor the trust closely and will not hesitate to take action if it fails to make the necessary improvements.”

Full details of the inspection are given in the report published online here

There had been an incident on Ashcombe ward on 31 July 2020 involving an open window that had been used as a ligature point. Changes had been made to Ashcombe ward to create an isolation area as part of the COVID 19 infection and prevention control strategy. The serious incident took place in an area of the ward that did not have good lines of sight due to the changes made to the ward environment. However, the trust had failed to identify that this left blind spots were staff could not easily observe patients.

There were a high number of vacancies particularly on Holcombe Ward, making it heavily reliant on bank and agency workers. Some staff were stressed and exhausted following the demands of the COVID 19 pandemic. Some shifts showed gaps in staffing which could potentially affect the safe care and treatment of patients. However, the trust had recognised the staffing difficulties and was actively recruiting and had plans in place to address staff shortages and support staff.

The CQC advised that the observation of patients needed improving. There was also a need for changes to the environment to ensure clear lines of sight were in place. This would help staff in observing patients.

Managers had not ensured the learning from incidents was communicated clearly with staff to allow risks to be managed effectively across all the wards.

Some staff told inspectors that the leadership of the service needed to be more supportive, and that managers needed to be more visible on the wards.

CQC also found that staff treated patients with compassion and kindness. They respected their privacy and dignity and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.


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