Wonford House Hospital

Updated 15 July 2014

Devon Partnership NHS Trust is a Mental Health and Learning Disability Trust which was established in 2001 and has six hospital sites across Devon and Torbay. The trust employs approximately 2,500 staff and also has 100 staff assigned from Devon County Council and Torbay Unitary Authority, including social workers and support workers. Devon Partnership NHS Trust serves a large geographical area with a population of more than 890,000 people and has an annual budget of around £130 million. The trust services fall into three areas of care:

Mental Wellbeing and Access – for people experiencing a common mental health problem for the first time who need more help than their GP can provide.

Recovery and Independent Living – for people with longer-term and more complex needs.

Urgent and Inpatient Care – for people with severe mental health difficulties, in crisis or experiencing distress and who may require a stay in hospital.

At any one time, the trust provides care for around 19,000 people in Devon and Torbay. The vast majority of these people receive care and treatment in the community. A small number may need a short spell of hospital care to support their recovery if they become very unwell and an even smaller number will have severe and enduring needs that require long-term care. Teams include psychiatrists, psychologists, specialist nurses, social workers, physiotherapists, occupational therapists and support workers.

Community services

Most of the people who receive services do so through a network of around 100 community teams offering a range of different services. These include teams supporting people who may be acutely unwell as well as those who need more long term care. There are also community teams meeting the needs of people with more specific needs such as pregnant women.

Hospital services

Wonford House Hospital is in Exeter, Devon. Devon Partnership NHS Trust have their head office at this site and also provide a number of services. We inspected the acute inpatient 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 Eating Disorder Service which is an inpatient eating disorder service which also accepts patients from across Devon and other counties.

The Care Quality Commission (CQC) has inspected the inpatient services at Wonford House Hospital three times since it was registered with Devon Partnership NHS Trust in 2010. The reports for these inspections were published in February 2011, December 2011 and December 2013. The reports in February and December 2011 found overall compliance but recommended some improvements. The report of December 2013 found the trust was meeting appropriate standards in respect of consent and supporting workers but action was needed in relation to aspects relating to the care and welfare of patients. Following this inspection the Trust sent us an action plan and then updates. The action plan stated that the trust had completed improvements, however our inspection found that these improvements had not been fully implemented and so we are taking enforcement action.

Updated 15 July 2014

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.

Updated 15 July 2014

We found that a good level of care was given across the community team services in Devon.

Care plans and risk assessments were usually complete but were not always updated quickly enough. We found examples of excellent practice, most notably in the Learning Disability team, and in the Older Person’s Mental Health teams.

Patients were positive about the care and treatment they received, and told us of warm and trusting relationships with the staff. Carers and relatives told us they felt engaged with the staff but not with the trust. This is because they were unsure of what the forthcoming service transformation would mean for them and their families.

Trust engagement with staff was variable. Staff told us they felt well-led at local level.Staff in the Recovery and Independent Living (RIL) teams were concerned about the length of time some patients who were not in a priority group were being “held” while waiting for a care co-ordinator and access to psychological therapies. This meant that, although their safety was being observed and monitored, they were not yet getting the treatment to enable fuller recovery.

We heard that the Iris Centre was a high performing service, where people with personality disorders were able to enjoy a safe and effective therapeutic environment.

Updated 15 July 2014

We found that crisis teams were held in high regard and generally provided a good service to the trust. However, a key issue for the crisis teams was the poor ‘out of hours’ cover for those people requiring urgent support. As there was only one nurse practitioner available overnight, they were not always able to answer the phone to people making a call. They had other duties to attend to and roles to perform. Sometimes this meant that calls to the answerphone were not received until the morning, therefore delaying the care needed for people requiring overnight urgent support.

We were told that the crisis house in Torbay was a new initiative, welcomed by the local community.

Updated 15 July 2014

We found that The Haldon Eating Disorder Service provided an effective, evidence-based treatment programme and a high standard of care. 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 cared for safely.

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 staff and each person 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.