- SERVICE PROVIDER
Essex Partnership University NHS Foundation Trust
This is an organisation that runs the health and social care services we inspect
Assessment report published 9 April 2026
Contents
Ratings - Long stay or rehabilitation mental health wards for working age adults
Our view of the service
439 Ipswich Road is an 11- bedded long stay or rehabilitation ward for male and female patients, provided by Essex Partnership University NHS Foundation trust. 439 Ipswich Road provides the following regulated activities:
- Assessment or medical treatment for persons detained under the Mental Health Act 1983
- Treatment of disease, disorder or injury.
We completed an unannounced inspection of the service on 21 November 2025. At the time of our inspection the ward was at full capacity.
The main house at 439 Ipswich Road consisted of 8 bedrooms, 2 with en-suite facilities and 6 with shared bathroom facilities. One bedroom was located on the ground floor and 7 were located on the first floor. The Coach House was an out-building with a communal kitchen and lounge. There was 1 ground floor bedroom with an en-suite, a first-floor bedroom with an en-suite and a self-contained flat.
The service was last inspected in August 2019, where there were breaches of regulation 9 (person centred care) and regulation 10 (dignity and respect). Patients did not have access to appropriate psychological therapies and informal patients were not always informed of their rights. The trust were told staff should assess the service for ligature risks, staff should be aware of safety incidents and lessons learned, staff should have access to a clinic room and staff should know how to access advice relating to Mental Capacity Act.
At this inspection we rated the service as requires improvement. We found 5 breaches in relation to regulation 9 (person centred care), regulation 12 (safe care and treatment), regulation 13 (safeguarding), regulation 17 (good governance) and regulation 18 (staffing). Due to the serious concerns that we found during the inspection we wrote to the provider and requested immediate actions. The trust were able to show how they had mitigated immediate risk to patients. Following this we issued the trust a warning. The trust were told they must address concerns relating to regulation 13 (safeguarding) and regulation 17 (good governance) of the Health and Social Care Act (regulated activities) Regulations 2014.
Staff did not consistently protect people from abuse. Safeguarding referrals were not always completed to protect patients from harm. Safeguarding concerns and sexual safety incidents were not appropriately managed. This meant patients were at risk of avoidable harm.
There were gaps within governance. Managers did not have adequate systems in place to monitor the assessment of risk. Staff did not always assess risks to people's health and safety, involve patients in risk assessments or mitigate risks when identified.
Managers did not have robust oversight of incidents. Incidents were not always appropriately investigated by managers and action was not always taken where concerns were identified. Learning from incidents was not always identified and embedded. Learning from incidents was not used as an opportunity for improvement and meant patients were at risk of continued harm.
Managers did not have adequate oversight of staff. Supervision and appraisal compliance was an average of 46% from May to October 2025. Clinical audits were not always completed as required. Staff did not always carry their personal alarms. This meant staff and patients were at risk of avoidable harm.
Managers did not ensure the environment was safe. There were ligature risks, fire risks and other environmental issues that were a risk to patients. This meant patients were at risk of avoidable harm.
Whilst there were adequate nursing staff, there was limited access to a responsible clinician and clinical psychologist which was not appropriate to support patients with their rehabilitation. This meant patients did not always have access to appropriate treatment for their rehabilitation.
There were some improvements since our last inspection. There was a clinic room where patients could be examined. Staff read patients their rights under the Mental Health Act. While access to the clinical psychologist was limited, there was a clinical psychologist in post.
People's experience of this service
We spoke with 6 patients during our inspection. Most patients felt safe at 439 Ipswich Road. However, one patient told us they did not feel safe at the service due to night staff sleeping and sexual safety concerns. We asked patients if they were able to access an independent advocate. Most patients said they did not have access or would not know how to access an advocate. Patients had a mixed view of activities available. Most patients reported that they got bored, while others told us there were lots of activities available. All patients we spoke with told us that staff were kind and respectful.
While the patients we spoke with expressed they were happy with their care, our assessment found the care did not meet the expected standards.