Essex Partnership University NHS Foundation Trust

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We looked for evidence that service leadership, management and governance assured high-quality, person-centred care, supported learning and innovation and promoted an open, fair culture. At our last inspection we rated this key question as requires improvement. At that inspection, the service was in breach of regulation 17 (good governance). At this inspection the rating remained requires improvement. We found a continued breach of regulation; this meant the management of the service was inconsistent.

This service scored 62 (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 shared vision, strategy and culture that was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding and meeting the needs of people and communities.

Staff felt respected, supported and valued. They said the service promoted equity and diversity in daily work and provided opportunities for development and career progression. They could raise any concerns without fear.

Staff knew and understood the service’s visions and values and how they were applied in the work of their team. Staff had the opportunity to contribute to discussion about the strategy for their service, especially where there were changes being made to the service. People and carers were involved in decision making about changes to the service. The senior leadership team had communicated the vision and values to staff and people who use the service.

Leaders were aware of any risks to delivering their strategy and had local action plans to address these that they monitored and reviewed for progress.

The service had inclusive leaders with skills, knowledge and experience to lead effectively and do so with integrity, openness and honesty.

Staff and people told us that leaders were visible on the ward, approachable and engaged well with them. Managers said they received good support from senior leaders.

Senior leaders were skilled, experienced and knowledgeable. Experienced leaders had a strong understanding of the service they managed.The ward manager had only been at the service for 9 weeks and was still learning about the service. They could explain clearly the improvements that have been made and how the team was working to provide good quality care.

The ward manager was new to post and had been at the service 9 weeks; they told us they were being well supported by senior leaders. Staff told us they found the ward manager approachable and supportive and that morale had greatly improved.

Leaders completed the Management Development Programme, which had been developed for all line managers, ranging from bands 4 to Associate Director, the programme was mandatory for all new leaders joining the trust.

The provider created a positive culture where people felt that they can speak up and that their voice would be heard

Staff were aware of the term ‘freedom to speak up’ and what this meant, however, not all staff knew who the trusts freedom to speak up guardians were, but they were able to explain how they would access freedom to speak up information if they needed it. Staff said they felt confident in speaking up and raising concerns, staff told us they felt listened to and where there was learning this was shared amongst staff.

The trust had policies in place that were in line with best practice guidance for freedom to speak up, whistleblowing and complaints. Between 1 July 2024 and 29 July 2025 there had been 3 freedom to speak up concerns raised. The themes were bullying and harassment and inappropriate attitudes and behaviours, which had all been escalated to the care unit leadership and being managed. Staff were given the opportunity to speak up and drive improvement through staff surveys, supervisions and meetings.

The service worked towards an inclusive and fair culture by improving equality and equity for people who worked there.

The trust had 5 staff equality networks where members worked with the trust to understand the needs of the communities and shape improvements. These networks were Ethnic Minority and Race Equality, Gender Equality, LGBTQ+, Disability and Mental Health, Faith and Spirituality. The trust held the Equality and Inclusion Committee which was embedded into their governance process. Feedback from staff, patient surveys, equality networks and data from the Workforce Race Equality Standards (WRES) and Workforce Disability Equality Standard (WDES) were used to inform trends and make improvements.

Leaders had taken action to review and improve the culture of the organisation in the context of equality, diversity and inclusion. Leaders had ensured reporting of racial abuse against staff was prioritised. The trust had added the category of racial abuse to the incident reporting system so that staff were able to report racial abuse and this was monitored. When reviewing incident records, we saw evidence that incidents of racial abuse were being reported.

Staff had access to the Resilience, Intelligence, Strength and Excellence (RISE) programme, a talent development programme aimed to improve Workforce Race Equality Standard (WRES) indicators. The programme was targeted towards Black and Ethnic Minority staff to enhance their career progression.

Staff undertook diversity and inclusion training annually. Staff we aware of information available on the intranet relating to equality and diversity.

The service did not always have clear responsibilities, roles, systems of accountability and good governance to manage and deliver good quality, sustainable care, treatment and support.

Leaders attended regular governance meetings for safety, audit, quality and governance. The trust discussed and addressed key areas of performance, risk, audit, culture and workforce. Minutes showed areas of concern were identified and actions taken to learn and improve.

Leaders completed regular audits on the ward, these included, matron audits, ward manager audits and person-centred care audits. However, these audits had failed to identify the concerns we found. These were where records were not being completed and kept up to date. For example, people’s health action plan had a list of medication but no information about their physical health conditions, the plan had not been updated to include any attended or planned health appointments, the hospital passport had also not been fully completed, risks associated with attending hospital had not been outlined, which meant the document did not communicate the person’s needs for any hospital visit/admission. Lack of important information in health action plans had been identified during a mental health act review monitoring visit in March 2025, but improvements had not been made as a result of this feedback.

A range of documents were available to staff with useful information, but information was not always recorded and updated consistently across records. For example, a person’s positive behaviour support plan said that they had ear defenders, but this information was not reflected in the care plan. We raised these concerns with leaders on our first visit, when we returned for our out of hours visit, work had been carried out to update records.

The systems and processes in place in the service had not been effective in identifying and mitigating these risks. Leaders told us that they had since introduced an extra layer of local auditing to ensure these things are identified. Leaders said they were also liaising with trust auditing leads to look at and review the questions that are being asked in audits. Further work was required to ensure governance systems were effective and fully embedded.

Staff said they had regular team meetings, situation report meetings to discuss any issues or risks, multidisciplinary team meetings, attended safety huddles, received regular lesson learned information and understood their roles. Staff felt the wards were well organised and managed. Staff were able to give examples of the checks they had participated in to ensure the safety of the wards such as security checks, observations, audits and checks of equipment. Staff gave feedback that they received regular supervision and appraisals.

Leaders explained how they communicated and interacted with staff to ensure they managed risk and sought staff views to make improvements. Leaders spoke about their responsibilities in relation to maintaining oversight of the services, by being present and ensuring they had managers and matrons on site. Leaders spoke about having oversight of capacity, budgets, audits, performance, key performance indicators and incident data. They shared clinical dashboards with teams for oversight and review.

The trust held a risk register for specialist services which we reviewed. All risks were identified with risk scores, controls, mitigations with assurance and action review dates. Leaders said staff could make suggestions to add to the risk register which would be escalated to the quality assurance meeting.

Staff knew how to deal with complaints and reported incidents and safeguarding concerns. Leaders shared lessons learned from investigating complaints, incidents and safeguarding issues.

The service understood its duty to collaborate and work in partnership, so the service worked seamlessly for people. Staff shared information and learning with partners and collaborated for improvement.

The service worked well with other agencies, there were established relationships between Byron Court and the Learning Disability Assessment and Treatment unit in North Essex, the matrons and the ward managers liaised regularly to share information and good practice. The service also worked with specialised learning disability colleagues in relevant local authorities, integrated care boards and the local acute hospital trusts.

Staff invited family members and external professionals to meetings so they could discuss any issues and receive any updates about people’s / their family member's care and treatment. People that we spoke with told us they were able to give feedback on how to improve the service they received.

Staffhad access to regular team meetings on the wards. Staff were able to propose, exchange and discuss ideas in terms of good practice. Staff could attend reflective practice sessions facilitated by the psychology department.

The servicehad appropriate processes in place to support effective links with the community and with partners. The trust sought feedback from staff, people and carers through surveys and used this feedback to make improvements.

The service focussed on continuous learning, innovation and improvement.

The ward manager subscribed to the Radiant Network which was a clinical and research network hosted by Hertfordshire Partnership University NHS Foundation Trust. It focussed on mental health and behavioural issues associated with intellectual disability, autism and other neurodevelopmental conditions. The ward manager was also of the UK Health and Learning Disabilities Network which connected people with an interest in the health of people with learning disabilities in the UK, they were also a member of the Royal College of Nursing’s Learning Disability Nursing Forum, information from these services and resources were shared with the team for learning and improvement.

The ward manager was registered with the Royal College of Psychiatrists Quality Network for Inpatient Learning Disability Services (QNLD) they participated in peer reviews with similar services, which supported the ongoing development and promotion of good practice through continuous learning.

The senior leadership team had a weekly support and reflective huddle which was open to all leaders in the service to attend. The forum was attended by all service leads and psychiatrists and was used to share information and reflect on current challenges. For example, leaders reflected on what more they could do to support the ward through high acuity, anticipated changes to the Mental Health Act and impact on learning disability services. The huddle was intended to offer a safe space for discussion and reflections.

The trust had 5 key messages that were shared with staff monthly, these were on the intranet. The service also kept a copy in the culture of learning folder, and we saw evidence of these messages being discussed in team meetings. The trust also sent out learning alerts, these included what happened, identified learning and actions required with a time frame for completion.

The trust had a lessons identified newsletter, this included learning from deaths, complaints, compliments and patient safety incident management.

Staff that we spoke with said leaders listened and considered any ideas staff shared with them for improving the service or about concerns around people’s care.