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

Our overall rating of well-led has stayed the same as good. Community health inpatient services for adults were rated as good.

This means 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 assessment we rated this key question good. At this assessment, the rating has remained good.

This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

At this assessment we identified breaches of regulations: 12 Safe Care and Treatment. Managers and leaders took immediate action to mitigate these risks.

Staff understood the provider’s vision and values and how these were embedded in their team’s work. The service created a positive culture where people felt that they could speak up. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. Leaders had oversight of risks, issues, and performance, which they reviewed regularly. The service worked closely with system wide partners across the community collaborative. The service focused on continuous learning, innovation, and improvement across the organisation.

This service scored 79 (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 a 3. The evidence showed a good standard. The service had a shared vision, strategy and culture that was based on transparency, equity, equality, and human rights. They considered diversity and inclusion, engagement, and understanding and meeting the needs of people and communities.

The provider’s senior leadership team had successfully communicated the provider’s vision and values to the frontline staff in this service. Staff knew and understood the provider’s vision and values and how they were applied in the work of their team. The visions and values are part of staff supervision and appraisal and how they embed into their work. We observed the providers values on notices on the ward. Managers told us they felt supported by senior leaders to change the culture on their ward.

The latest strategic plan was 2023-2028. Staff were included as part of the strategy’s development. Staff had the opportunity to contribute to discussions about the strategy for their service, especially where the service was changing.

We scored the service as a 3. The evidence showed a good standard. The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. They had the skills, knowledge, experience, and credibility to lead effectively and do so with integrity, openness, and honesty.

Leaders had the skills, knowledge, and experience to perform their roles. Staff and patients talked positively about the leaders on the wards.

Leaders had a good understanding of the services they managed. They could explain clearly how the teams were working to provide high quality care.

Leaders were visible in the service and approachable for patients and staff.

Leadership development opportunities were available, including opportunities for staff. Managers and staff told us they had been given opportunities to progress in their roles. The provider had a programme in place to support colleagues enhance their confidence, leadership, and transferable skills and to support them with developing their career.

Staff had management development opportunities for staff including management and leadership development programmes and apprenticeships. Leaders we spoke to were knowledgeable and visible on the wards. Leaders analysed results from the latest staff survey (July 2025) and produced an action plan.

We scored the service as a 3. The evidence showed a good standard. The service created a positive culture where people felt that they could speak up and that their voice would be heard.

During the period December 2024 to April 2025, there were 4 contacts made to the Freedom to Speak up (FTSU) Guardian which were responded to appropriately. Staff told us they felt confident to raise concerns and would look on the intranet for the process to follow if they wanted to raise a concern to the FTSU Guardian.

All staff completed FTSU training. Training compliance was 94% and 93% had completed the follow up training.

Patients and carers had opportunities to give feedback on the service they received in a manner that reflected their individual needs. There were a number of ways that feedback could be given including compliance visits by the leadership team.

The latest staff survey (July 2025) was completed by 67% of staff (1% up from last year).

Managers and staff had access to the feedback from patients, carers and staff and used it to make improvements.

We scored the service as a 4. The evidence showed a good standard. The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who work for them.

The provider produced an Equality Diversity and Inclusion monthly report, which was presented to the People’s committee and the Board of Directors. The report for example reviewed black history month and national inclusion week, reviewed the equality diversity and inclusion (EDI) plan and EDI objectives for directors.

The quarterly leadership development programme included in quarter 3 leading for inclusion, for example psychological safety and how a lack of inclusion and equity impacted on staff, services, and patients. The provider has signed up to the NHS Sexual Safety Framework which commits to zero tolerance approach to any unwanted inappropriate or harmful sexual behaviours in the workplace.

The board of directors reviewed 2025 data from Workforce Disability Equality Standard (WDES) and Workforce Race Equality Standard (WRES) to identify areas of improvement. There was an action plan in place for both WRES and WDES.

Staff could apply to work flexibly to account for personal circumstances such as caring responsibilities and health issues. Managers put reasonable adjustments in place for staff members to help them conduct their role.

We scored the service a 3. The evidence showed a good standard. The service had clear responsibilities, roles, systems of accountability and good governance to manage and deliver good quality, sustainable care, treatment, and support. They acted on the best information about risk, performance, and outcomes, and shared this securely with others when appropriate.

There was a clear framework of what must be discussed at a ward, team, or directorate level in team meetings to ensure that essential information, such as learning from incidents and complaints, were shared and discussed.

Quarterly learning events took place and brought colleagues together from across the trust. This included clinical and non-clinical, people with lived experience and partners. A learning event in November 2025, included a session on quality improvement (QI) projects and initiatives promoting system learning.

Governance systems were in place to ensure there was trust wide information and sharing and learning, there was a learning collaboration partnership group and a learning oversight subcommittee. A lessons team collaborated with all teams and subject matters experts to consider how learning can be captured, analysed, raised, or resolved and embedded with a practice. This team was made up of staff across the trust.

The trust had a monthly lesson learnt newsletter for staff this included patient safety incidents what went wrong, what good looks like and action this month.

Staff at the service level, had implemented recommendations from reviews of deaths, incidents, complaints, and safeguarding alerts.

Staff undertook or participated in local clinical audits. The audits were sufficient to provide assurance and staff acted on the results when needed. Audits formed part of the Quality Assurance Audit Programme and took place daily weekly or monthly. Data was included from these audits to inform national audits for example, at the end of life, and inpatient falls.

Staff understood the arrangements for collaborating with other teams, both within the provider and external, to meet the needs of the patients.

Staff had access to the equipment and information technology needed to do their work. The information technology infrastructure, including the telephone system, worked well and helped to improve the quality of care. However some staff told us they needed more computers on the ward, the NHS Wi-Fi did not always work well and patients who had tablet devices could not watch films.

Information governance systems included confidentiality of patient records. Team managers had access to information to support them with their management role. This included information on the performance of the service, staffing and patient care. Information was in an accessible format, and was timely, accurate and identified areas for improvement.

We scored the service as a 3. The evidence showed a good standard. The service understood their duty to collaborate and work in partnership, so their services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

Directorate leaders engaged with external stakeholders for example commissioners and Healthwatch.

We observed Multi-Disciplinary Team (MDT) meetings indicated collaboration with family members, key stakeholders, and care teams in relation to the patient journey. External colleagues from local authorities provided positive feedback of working with ward teams.

Patients and staff could meet with members of the provider’s senior leadership team and commissioners to give feedback. Leaders visited the wards and provided online opportunities for staff to engage.

Nurse led ward leadership meetings gave an opportunity for the ward managers to communicate with senior leaders. Patient assessors visited the wards and completed assessments were sent to NHS England for analysis and benchmarking.

We scored the service a 3. The evidence showed a good standard. The service focused on continuous learning, innovation and improvement across the organisation and the local system. They encouraged creative ways of delivering equality of experience, outcome, and quality of life for people. They actively contributed to safe, effective practice and research.

Staff used quality improvement methods and knew how to apply them. Staff were given the time and support to consider opportunities for improvement and innovation and this led to changes. Managers told us they communicated with the MDT and shared improvement and ideas.

Innovations were taking place in the service. Each ward had an improvement plan in place. Avocet ward introduced Quality Improvement (QI) training for all staff including protected time to complete the training and were considering alternative storage for the ward. CICC were considering a handbook for relatives and for patients and supporting nurses to undertake the independent non-medical prescriber course.

Staff participated in national audits relevant to the service and learned from them. Staff told us there were Quality Improvement projects taking place on the wards, for example working with neighbouring hospice staff who were collaborating with staff on the wards.