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

Our overall rating of safe has changed to requires improvement.

This means we looked for evidence that people were protected from abuse and avoidable harm.
At our last assessment we rated this key question as good. At this assessment, the rating has remained as requires improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of regulation for safe care and treatment.

The service did not always make sure that medicines and treatments were safe, available, and met people’s needs, capacities, and preferences. The service did not always detect and control potential risks in the care environment and make sure that the equipment, facilities, and technology support the delivery of safe care. Staff had not all received the mandatory training for their roles.

However, patient areas were safe, clean, well equipped, well furnished, well maintained and fit for purpose. Staff assessed and managed risks to patients and themselves well. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. The service managed patient safety incidents well.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We scored the service as 3. The evidence showed a good standard. The service had a proactive and positive culture of safety based on openness and honesty, in which concerns about safety were listened to, safety events were investigated and reported thoroughly, and lessons were learned to continually identify and embed good practices.

There was 1 serious incident reported in the last 12 months. This was an expected death from natural causes and not a patient safety incident. The trust used the Patient Safety Incident Response Framework (PSIRF). This is the overarching framework for how to respond to all patient safety incidents. The Trust was one of the first ‘early adopter’ Trust’s to work to the PSIRF, as part of the East region early-adopters group led by the Northeast Essex and Suffolk Integrated Care System (ICS) in 2020/21

Staff reported incidents appropriately. Staff told us if there was an incident then they would pull the alarm and a doctor would respond. Staff also told us they talk to the nurse in charge and if a doctor was not on site they would call the emergency services. If a falls alarm sounds staff told us they would check on the patient and wait for a nurse. Appropriate recording and reporting was completed and families were made aware.

Staff received feedback from investigation of incidents, both internal and external to the service. Staff told us learning from incidents was shared in team meetings and all staff received a monthly update from the trust with learning.

Managers told us they review the Datix, they hold team meeting huddles and have a lesson learnt folder on the ward for staff to read. Weekly leadership meetings took place, safety and Datix incidents were discussed and how these would be escalated to the team. Staff were debriefed and received support after a serious incident.

We scored the service as 3. The evidence showed a good standard. The service worked with people and partners to establish and maintain safe systems of care, in which safety was managed, monitored, and assured. They ensured continuity of care, including when people moved between different services.

The service’s referral and admission processes ensured that all essential information about the patient was received to determine if the patient’s needs could safely be met. There was a thorough assessment undertaken prior to the patient being admitted onto the ward to ensure they were suitable for rehabilitation. This included history and physical examination. The therapy team aimed to see patients on the day of admission.

Patients being transferred from acute hospital had to have a completed discharge information form prior to admission. When the Princess Alexandra Hospital was under extreme bed pressures, the hospital policy allowed the wards to admit without this form being completed if a clinician had conducted a verbal handover to support the transfer.

Both wards we assessed were rehabilitation wards. After a short period of rehabilitation and therapy, the patient returned to the community either to their own homes, to live with relatives or a care setting. Leaders and staff told us discharge planning starts from the first day a patient comes onto the ward. Managers at the CICC ward told us that flow meetings happen 3 times a day to ensure that the team are constantly updated with patients being admitted and discharged from the ward.

Staff involved all the necessary healthcare and social care services to ensure patients had continuity of safe care, both within the service and post-discharge.

Patients told us discharge was well planned with assessments, joint meetings, home visits, and equipment delivered to their homes. We observed 2 multidisciplinary team meetings where patients discharge needs were individually discussed. Therapy staff and medical staff attended these meetings. There was no hospital social worker or discharge coordinator on Avocet ward, therapists led this meeting. On the CICC ward the discharge coordinator led the meeting. The teams discussed funding for patients who were returning home and required care. The team discussed patients’ mobility requirements, and any equipment needs, medication and side effects.

We scored the service as 3. The evidence showed a good standard. The service worked with people to understand what being safe means to them as well as with their partners on the best way to achieve this. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm, and neglect, and made sure they shared concerns quickly and appropriately.

Nursing staff and medical staff received training specific for their role on how to recognise and report abuse. All staff completed mandatory safeguarding training, and at the time of assessment across all 5 wards, compliance was at 92.4% for safeguarding adults and children level 2 and 86.2% for level 3 safeguarding adults.

Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act.

Staff knew how to identify adults and children at risk of, or suffering, significant harm and worked with other agencies to protect them. Staff knew how to make a safeguarding referral and who to inform if they had concerns. Managers and staff were able to explain the process of making a referral to the local authority and completing a Datix entry. Managers told us they supported staff and afterwards would consider any learning and if they could improve. Staff and managers told us they can contact the safeguarding team for advice and guidance.

Staff gave an example of conducting a Mental Capacity Assessment for a patient where there was a safeguarding concern.

Staff followed safe procedures for children visiting the ward. There was a separate visitors room off the ward used when children were present.

Leaders monitored safeguarding incidents across the wards and identified any themes.

We scored the service as 3. The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically so that care meets their needs in a way that is safe and supportive and enabled them to do the things that mattered to them.

Risk assessments were completed on admission and updated if patients deteriorated or improved. We reviewed 9 patient records, 5 in detail, of those all 5 had a risk assessment and risk management plan in place.

Staff involved patients in care planning and risk assessment. Within care plans we observed evidence that patients had been involved in discussions on admission to inform the care plans. Patients told us they had been involved in discussions about discharge planning and had participated in multidisciplinary team reviews.

Staff spoke with patients so that they understood their care and treatment, including finding effective ways to talk with patients with communication difficulties. We observed staff taking time with patients to explain their care and treatment and discharge plans to them. Patients told us that the therapy teams spoke to them regularly and explained what therapy they would be receiving.

Staff enabled patients to give feedback on the service they received. Patients told us they could talk to staff and doctors if they have any concerns. One patient told us she had put a review on social media about the excellent care and treatment she had received.

Staff ensured that patients could access advocacy.

Staff used a nationally recognised tool to identify deteriorating patients and escalated them appropriately.

Staff shared key information to keep patients safe when handing over their care to others. Shift changes and handovers included all necessary key information to keep patients safe. Managers and staff told us they had huddles every morning to discuss any concerns from the previous shift.

We scored the service as 2. The service did not always detect and control potential risks in the care environment and make sure that the equipment, facilities, and technology support the delivery of safe care.

We found concerns in the clinic rooms on both wards. In the CICC there were 2 items in the emergency grab bag which were out of date. The AED pads (pads used to attach to a defibrillator) had expired in October 2025 and the Igel (adult airway device used in first aid) expired October 2025. On Avocet ward, suction tubing on the resuscitation trolley had expired.

Since our on-site assessment, managers and leaders have ensured out of date equipment was removed and new AED pads in place.

However, staff carried out regular risk assessments of the care environment. Health Safety and Security workplace inspections were carried out regularly across the wards and a green, amber, red code used to identify any actions required. Fire safety and Health and Safety Inspections are carried out regularly across the wards.

Staff had easy access to alarms and patients had easy access to nurse call systems. Patients had access to fall monitors which alerted staff if the patient had a fall, staff explained this was a better solution for patients than pressure mats which could be a trip hazard. We did however find the alarms on Avocet ward very loud and the temperature very warm, which we raised with the manager. There were maintenance staff on the ward that day to resolve the heating concern. The trust told us the alarm volume is appropriate for the ward layout and must be audible from one end of the corridor to the other to ensure safety.

The wards were clean and bright. CICC were colourfully decorated with pictures by a relative of a patient. The service had suitable facilities to meet the needs of patients’ families. Avocet had a day room which provided facilities for families to make themselves a hot drink.

Clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly. On both wards the occupational therapy bedroom, kitchen and workshop were all clean and well equipped.

Patients could reach call bells and staff responded quickly when called. Patients told us that when they used their call bells staff responded.

Staff carried out daily safety checks of specialist equipment. The service had enough suitable equipment to help them to safely care for patients.

We scored the service as 2. The service made sure there were enough qualified, skilled, and experienced people, who received effective support, supervision and development and worked together effectively to provide safe care that meets people’s individual needs. However not all staff had completed their mandatory training.

At the time of the inspection on Avocet Ward only 73% and on Beech Ward 74% staff had completed Basic Life Support training and only 69% staff had completed Immediate Life Support training. The hospital told us however that all staff who require this training were booked onto the next available course. Staff were up to date with all other appropriate mandatory training.

The service was a nurse led service and had medical staff available during the day. This included a ward doctor and consultant. The service always had a consultant on call during evenings and weekends.

At the time of the assessment all 5 wards had staffing establishment figures of 65.56 full time equivalent (FTE) registered nurses and 114.95 FTE healthcare assistants. The service vacancies for healthcare assistants were 10.82 and 7.09 for registered nurses.

The number of shifts covered by bank staff across the 5 wards for the 3 months August to October 2025, was an average of 800 per month with Beech Ward the highest with 343 shifts. Leaders told us this was due to long term sickness on this ward. The trust sickness policy and a local task and finish group were managing this to ensure procedures were being followed to support staff to return to work. Avocet ward had an average of 73 shifts and the CICC 165. Managers at Avocet and CICC wards told us that most shifts that needed to be covered for staff sickness and holidays was by bank staff and very rarely agency staff. Managers asked other matrons if they had staff to support. The trust ensured us all bank staff undertook a local induction and were familiar with the ward environment and the patients they supported.

Staff sickness on the wards from May to October 2025 was an average of 9.5% and staff turnover 9.25%.

Managers regularly reviewed and adjusted staffing levels and skill mix and gave bank staff a full induction. Managers told us how they had been supported to complete their nursing qualifications while working at the hospital. On Avocet Ward staff and managers told us there has been a recent change in shift patterns and staff are no longer working 12-hour shifts.

The service had enough medical staff to keep patients safe. Managers told us doctors were available during the day from 9-1pm and patients were seen on the ward rounds and new patients on the day of admission. On the CICC, a stroke consultant visited the ward once a week. Doctors also reviewed long term disease management. For example, the treatment of constipation and high blood pressure.

Clinical staff completed training on recognising and responding to patients with mental health needs, learning disabilities, autism, and dementia. Managers monitored mandatory training and alerted staff when they needed to update their training. The training was appropriate for the patient group using the service.

We scored the service as 2. The service assessed and managed the risk of infection, detect and control the risk of it spreading and share any concerns with appropriate agencies promptly.

We found that clinical waste was not appropriately disposed of. We found clinical gloves in black bins on Avocet ward. However, the hospital took immediate actions to remedy this and reminded staff of the correct procedure for disposal of clinical waste.

There were adequate hand-washing facilities and antibacterial hand gel was available. The hospital conducted regular hand-washing audits. Cleaning records were up-to-date and demonstrated that all areas were cleaned regularly. Wards were clean and tidy and regular cleaning audits were completed. Cleaning audits were viewed while on inspection and they all showed good scores. The October 2025 audit for Avocet Ward scored 99% and the CICC 97%.

Whilst visiting Avocet ward we observed 2 patients being nursed in isolation due to suspected infections. We observed signs on the doors reminding staff to wear eye protection, aprons, gloves, and masks and to use infectious control waste bins.

Staff followed infection control principles including the use of personal protective equipment (PPE). Staff cleaned equipment after patient contact and labelled equipment to show when it was last cleaned.

We scored the service as a 1. The evidence showed some shortfalls. The service did not always make sure that medicines and treatments were safe and met people’s needs, capacity, and preferences.

In the medication room in the CICC we found an expired oxygen cylinder and another cylinder we could not read so the amount of oxygen was unknown. Staff advised these were not used and in date oxygen was in the medication room.

On Avocet ward medication room, we found medicines left on the counter and counters cluttered with items needing maintenance. We found out of date medication, plasma solution which had expired in May 2025 and 2 boxes of iodine dressings which had expired in Sept 2025. We observed Biobank bin for excess medicines had confidential patient labels. However the trust told us, at the time of the inspection, the nurse responsible had been called away urgently to respond to a patient emergency on the ward. Immediately after resolving the emergency, the medication was returned to the cupboard without delay. The medication was not left unattended as part of usual practice, and the incident arose solely due to the need to prioritise urgent patient care.

Since the on-site assessment managers and leaders have ensured that all out of date medicines and oxygen cylinders have been removed, staff have been reminded of the importance of checking medicines and dressings to ensure out of date items were disposed of correctly, and disposal of patient identifiable medication.

However, there was a recent up to date policy for the safe and secure handling of medicines and pharmacists visited the wards weekly or fortnightly. The service and staff told us learning from all medication incidents across the wards was shared amongst the teams and discussed routinely at team meetings, safety huddles and at quality and safety meetings.

Staff followed systems and processes to prescribe and administer medicines safely. Staff reviewed each patient’s medicines regularly and provided advice to patients and carers about their medicines.

Staff completed medicines records accurately and kept them up to date. Staff learned from safety alerts and incidents to improve practice.