Essex Partnership University NHS Foundation 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

We looked for evidence that people were protected from abuse and avoidable harm. At our last assessment, we rated this key question as requires improvement. At that assessment the service was in breach of regulation 12 safe care and treatment and regulation 18 staffing. At this assessment, the rating changed to good.

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.

The service had a proactive culture of safety based on openness and honesty, in which concerns about safety were listened to, safety events were investigated, reported thoroughly, and lessons learned to continually identify and embed good practice.

Staff knew what incidents to report and how to report them. Staff reported incidents clearly in line with trust policy. Staff recorded incidents on an electronic incident reporting system. All incidents were reviewed by the ward manager. In the last 12 months, staff had reported 33 incidents. Incidents included self-harm, assault and contact with an object. There were 24 incidents classified as no harm and 9 incidents of low/minor harm. We reviewed these incidents, and they included how staff managed the incident, lessons learned from incidents and actions taken to embed learning.

Staff were de-briefed and received support after an incident. People were de-briefed after incidents in ways that supported their communication needs. The person we spoke with told us they had received a de-brief after incidents, and they found them helpful.

Leaders investigated incidents. Leaders and staff were able to give examples of learning from recent incidents, which had identified training needs for staff, this additional training had been organised by leaders, learning from this was also discussed in team meetings and supervisions, we observed this in minutes from meetings and supervision records.

Staff received feedback from the investigation of incidents, staff met to discuss feedback, lessons learned and to continually identify and embed good practice.

Staff understood duty of candour. They were open and transparent and gave people and families a full explanation when things went wrong.

The service worked with people and partners to establish and maintain safe systems of care, in which safety is managed, monitored and assured. The service ensured continuity of care, including when people moved between services.

People told us they felt safe on the ward, people said when they were admitted they were given a welcome pack with information in their preferred communication method. Carers told us the ward was welcoming, they said they had been involved in discussions about discharge planning but at present their relative wasn’t ready for discharge.

Throughout people’s stay on the ward they were visited regularly by the community team to prepare for discharge.

From April 2025 to June 2025 the service had 1 delayed discharge each month. The service attended a fortnightly ‘Building the Right Support’ meeting with all system partners where discharge pathways for people were discussed. There was also an additional meeting held fortnightly with aim to give oversight and escalation of people who were classed as delayed discharge. The meeting was chaired by the transforming care lead.

The ward team had effective working relationships with teams outside of the service. For example, external teams told us that multidisciplinary team working between both teams on planning and sustaining discharge was really positive, they felt the investment of the team at Byron Court supported them to achieve their function, and there was a strong person-centred approach.

The service worked with people to understand what being safe meant to them as well as partners on the best way to achieve this. The service concentrated on improving people’s lives while protecting their right to live safely, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

Staff received training in safeguarding at levels 1, 2 and 3 and staff kept up to date with their safeguarding training. Staff compliance with safeguarding training level 1 was 100%, level 2 was 85.7% and level 3 was 90.9%.

Staff knew who to inform if they had a safeguarding concern. In the last 3 months, 3 safeguarding referrals had reached the threshold for investigation by the local authority. These investigations related to self-harm, lessoned learned had resulted in actions taken by the ward manager, including, extra support and training for staff, competency checks and regular discussion in supervisions and team meetings, a self-harm safety plan had also been developed with the person, this detailed the reasons the person self-harmed and different ways staff should support them. When safeguarding incidents involved staff members, leaders took action to ensure the incident was investigated thoroughly, and the person was then made safe and supported. Staff at the service worked alongside the local authority in conducting all safeguarding investigations. We saw evidence of staff supporting a person by raising a safeguarding alert when the person had disclosed allegations regarding a previous placement.

Staff knew how to recognise adults and children at risk of or suffering harm and worked with other agencies to protect them. Staff could give examples of how to protect people from harassment and discrimination, including those with protected characteristics under the Equality Act 2010.

Staff followed clear procedures to keep children visiting the ward safe. Children were not permitted to visit people on the wards. Visits from children took place in other areas.

Staff could recognise signs when people experienced emotional distress and knew how to support them to minimise the need to restrict their freedom to keep them safe. People were only restrained only where evidence demonstrated it was necessary and for the minimum period of time. Staff made every attempt to avoid using restraint by using de-escalation techniques and restrained people only when these failed and when necessary to keep the person safe. Staff understood the Mental Capacity Act definition of restraint and worked within it.

In the previous 3 months there had been 17 episodes of restraint, this had reduced each month, in May there was 9 episodes, in June there was 6 episodes and in July there was 2 episodes. Rapid tranquilisation had been used on 5 occasions between May 2025 and July 2025. At the time of our inspection 81.8% of eligible staff had received trauma and self-injury (TASI) training, 3 staff had not completed the training due to known circumstances and were unable to complete it at this time. Leaders attended regular restrictive practice group meetings.

The service did not always work with people to understand and manage risks by thinking holistically so that care met their needs in a way that was safe and supportive and enabled them to do things that matter to them.

Staff completed risk assessments for people on admission and reviewed these regularly, including after any incident. Staff told us they involved people and carers in care planning and risk assessment. People and carers told us that staff met with them regularly to review care plans and positive behaviour support plans, they felt they were included in care and treatment and able to contribute.People had signed their care plan and had a copy, carers also told us they had a copy of the care plan.

Staff had co-produced a personal safety plan for self-harm with a person. It detailed the reasons the person may self-harm, and different ways staff should support the person, depending on the reason and emotion they were feeling, there was a display of emotions the person could point to,as they found it difficult to communicate when they were feeling distressed. The person said they felt well supported and safe.

Where there were restrictions on people’s freedom, these were discussed and recorded. The service had a list of prohibited items. The service had an easy read version of the blanket restrictions and prohibited items in place. People did not have unrestricted access to outside space, however, staff facilitated access to the garden. People said they felt the restrictions on the ward made sense. Carers told us their relative was safe on the ward and staff managed safety well.

Staff we spoke with showed a good understanding of the management of risk and reducing restrictive interventions. Staff spoke about using restraint and seclusion as a last resort and examples of interventions they would use to manage and de-escalate situations, staff were aware of people’s positive behaviour support plans and referred to this, staff said they found them helpful. However, the positive behaviour support plan for a person on the ward was not located on the first day of the inspection as the ward manager told us it had not been completed yet and they were using a plan from a previous service.

The trust had a reducing restrictive interventions policy which included guidance and procedures for managing and reducing restrictive practice. The trust held monthly restrictive practice group meetings, we reviewed the minutes from these meetings, where all areas of restrictive practice were presented. People we spoke with said they felt safe on the ward and that restrictions on the ward made sense.

Staff completed and regularly updated thorough risk assessments of ward areas and removed or reduced any risks identified.

Staff regularly reviewed the environment, identified and managed ligature risks, and mitigated risks quickly to keep people safe. The service had recently purchased anti ligature furniture for the dining room. Leaders ensured staff on the ward had easy access to ligature packs with information on environmental risks, this included a map of hotspot areas. Staff we spoke with knew about any potential ligature anchor points and knew where ligature cutters were located, staff could describe mitigations taken to reduce risk to people’s safety. We saw from staff meeting minutes that ligature audits, and their findings were shared and discussed.

Staff could not observe people in all parts of the ward. This risk was identified and recorded within the ligature risk assessment and mitigated using convex mirrors, CCTV and staff observations. At the time of our inspection 100% of eligible staff had completed suicide by ligature prevention training.

The ward used CCTV in communal areas and could use this to review safety incidents. There was a sign to let people and visitors know about the use of CCTV. At all times, 2 members of staff wore body worn cameras, this always included 1 person allocated to observations.

The service was a mixed sex ward; there was a male bedroom corridor and a female bedroom corridor. The corridors were kept unlocked and people had keys to their own bedrooms and people could access their bedrooms without asking staff. There was a process in place for staff to continuously observe the corridor doors when people were present in the communal areas to ensure safety and wellbeing. Estates work had recently been completed and the corridor doors had been moved back towards the bedroom areas to offer more communal space and access to the laundry and sensory room.

Staff had easy access to alarms and people had easy access to nurse call systems, staff also had access to a mobile phone. The service had also purchased radios and were waiting for their radio licence before introducing these.

The service had policies to follow fire and safety practices on site. There was a fire escape plan and fire action notices on the ward which showed the assembly point.

The ward had a dedicated seclusion room. Staff needed to look through 3 different windows to ensure constant observation. There was digital clock with the time and date opposite the room that could be seen if the blind was kept open. The seclusion room had no division between the toilet and sink area and the main seclusion room, there was no shower, people would need to be escorted across to the shower in the Long-Term Segregation area. Leaders told us that there was a plan in place to refurbish the seclusion room, and the funding had been agreed, the plan included changing the layout of the room and included a shower.

Each person had their own bedroom and en-suite bathroom, which they could personalise. People had a secure place to store personal possessions in their bedroom.

The ward had a range of rooms and equipment to support treatment and care. The ward had a quiet room and quiet areas people could use. The ward had a room where visitors could come and meet people, there were alternative rooms off the ward to use if a child was visiting. The ward had a communal living room.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development and worked together effectively to provide safe care that met people’s individual needs.

The service had enough nursing and support staff to keep people safe. At the time of our inspection Byron Court had capacity for 7 people. Leaders had calculated the number and grade of nurses and healthcare assistants required based on people’s needs.

The service had low vacancy rates. The service did not use agency staff, the service used regular bank staff where needed. Over the last 3 months there had been an increase in the use of bank staff; which leaders told us was due to sickness, annual leave, training, and people’s needs. When bank staff were used, they had received the trust induction and training and were familiar with the ward, staff and people.

The service had a high turnover rate. For the last 12 months, staff turnover for the service in June 2025 was 19.6%, this exceeded the trust target of 12%. The service had a high staff sickness rate of 11.5% in May 2025, this exceeded the trust target of 5%.

The ward manager could adjust staffing levels according to the needs of the people. Staffing needs were discussed daily in meetings.

Staff levels allowed people to have a regular one-to-one time with their named nurse. Throughout the inspection we observed enough staff on the ward to facilitate activities. People and carers told us there was always enough staff.

There were enough staff to carry out physical interventions and observations safely and staff had been trained to do so.

There was adequate medical cover day and night, and a doctor could attend the ward quickly in an emergency.The service operated an out-of-hours rota for doctors.

Staff had received appropriate mandatory training. Staff compliance with mandatory training was between 81.8% and 100%; this was due to sickness and a new staff member.

Staff compliance with The Oliver McGowan mandatory training on learning disability and autism was 100%. Additional to this, staff at Byron Court completed specialist learning disability and autism training, This had improved since our last inspection.

The mandatory training programme was comprehensive and met the needs of people and staff. Leaders monitored mandatory training and alerted staff when they needed to update their training.

The service had access to a range of specialists to meet the needs of people on the ward. The service employed a matron, ward manager, deputy ward manager, doctors, nurses, healthcare assistants, psychologists, speech and language therapists and occupational therapists.

Leaders ensured staff had the right skills, qualifications and experience to meet the needs of the people using the service, Leaders had identified that although they had a stable staff team a lot were newer staff, so they had organised extra training sessions to support progress and upskill them.

All staff attended the trust induction programme and shadowed experienced staff before they were fully incorporated into the staff numbers.

Leaders supported permanent staff to develop through yearly, constructive, comprehensive appraisals of their work. At the time of our inspection, 85.9% of staff had received an appraisal.

Leaders supported staff through regular constructive and comprehensive supervision of their work. At the time of our inspection 100% of staff had received supervision.

Leaders recognised poor performance, could identify the reasons, and managed these. The ward manager had identified concerns around observations and as part of the learning from this had organised additional training for staff, carried out competency checks, and followed up by regularly discussing observations in supervisions and in regular monthly team meetings.

The service assessed and managed the risk of infection, detected and controlled the risk of it spreading and shared any concerns with appropriate agencies promptly.

The ward area was visibly clean, tidy and had good furnishing. The ward kept up-to-date cleaning records that demonstrated that the ward area was cleaned regularly. Staff maintained equipment well and kept it clean. The service followed their infection control policy, including hand washing. The service carried out monthly infection prevention and control audits, which included checks on personal, protective equipment (PPE), handwashing, equipment, cleanliness and mattresses. In April and May 2025, the service scored 100% on these audits.

People and carers told us the ward was always clean and tidy.

Staff completed Infection, Prevention and Control training. Compliance in June 2025 for level 1 was 100% and level 2 was 92%.

The trust had a detailed Infection Prevention Control policy, which was reviewed regularly. A policy ‘at a glance’ with staff responsibilities was also available.

The service ensured that medicines and treatments were safe and met people’s needs, capacities and preferences by enabling them to be involved in planning, including when changes happened.

Staff accurately recorded administration of medicines. This had improved since our last inspection. Staff followed good practice in medicines management (which included, transport, storage, dispensing, prescribing, administration, medicines reconciliation, recording and disposal) and in line with national guidance. There were specific systems in place for the management of controlled drugs and medicines that were liable to be misused.

Medicines were stored appropriately. Medicines cupboards were locked when not in use. Medicines prescribed for individual people were labelled and stored correctly. Staff kept up-to-date information about stock. Details of pharmacy contacts were displayed for staff to see easily. Staff knew how to dispose of medicines and associated equipment safely. Staff kept accurate records of medicines. Sharps bins were available on the ward and were marked with the date of opening, as needed. Staff kept records of national medicines alerts and recorded what action they needed to take to improve practice.

The service ensured people’s behaviour was not controlled by excessive and inappropriate use of medicines.

The service reviewed people’s medicines regularly and provided advice to people and carers about their medicines. People’s medicines were reviewed as part of their overall review of their progress at ward rounds. Staff provided information about possible side effects. People were involved in discussions about medicines and care planning. Pharmacists carried out medicines audits. The clinic room was clean, orderly and fully equipped. Cleaning records were available and completed. Staff recorded daily room and fridge temperatures to ensure the safe storage of medicines.

Blood glucose machines were fully calibrated. This had improved since our last inspection. Equipment to support physical health care was available, regularly cleaned, audited and calibrated in line with manufacturer guidance.

The service had emergency medicines and emergency equipment available. Its location was clearly marked in clinic rooms. There was an oxygen cylinder available in the clinic room which was in date. Records showed staff carried out regular checks of the defibrillator and resuscitation equipment.