Essex Partnership University NHS Foundation Trust

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• 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

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 inspection, the rating changed to inadequate. The trust were in breach of regulation 12 (safe care and treatment) and regulation 13 (safeguarding).

Managers did not ensure the ward was safe. Safeguarding referrals were not always completed when there was a safeguarding incident. Staff did not always assess risks to people's health and safety, involve patients in risk assessments or mitigate risks when identified. Patients did not always have risk assessments in place on admission. Incidents were not always appropriately investigated by managers and actions following investigations did not mitigate risk to patients. Learning from incidents was not always identified and embedded. Failure to risk assess, safeguard and learn from incidents puts patients at risk of ongoing and avoidable harm.

Managers did not ensure the environment was safe. There were ligature risks that had not been mitigated. There were fire risks around the buildings. We observed cleaning liquid in a paper cup in the Coach House. There was a large hole in the garden fence, where patients could abscond. There were broken appliances in the garden and there were garden tools in an unlocked shed. The environment put patients at risk of avoidable harm.

Leaders did not ensure there were appropriate staff to support patients in their rehabilitation. There was limited face to face access to a responsible clinician.

External care workers were involved in patient care. There were crisis management plans in place. There were no incidents of restraint, rapid tranquilisation or seclusion taking place. There was a clinic room, which was locked when not in use.

This service scored 38 (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 1. The evidence showed significant shortfalls. The service did not have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

Leaders failed to fully investigate or identify learning from incidents. In addition, they did not ensure that the local safeguarding teams were alerted when there had been a safeguarding incident or concern. In the last 6 months there were 69 incidents recorded. We found evidence of 6 sexual safety incidents, 6 incidents involving staff, 10 incidents of patients absconding and 2 incidents where patients had reported items lost or stolen. For incidents where patients had reported money missing, staff advised the patient to lock the money in their drawer or in the safe but took no further action or learning to minimise the risk of repeated incidents.

Patients and staff had reported sexual safety concerns. We did not see appropriate actions were taken following sexual safety incidents being reported. Learning was not identified and risk mitigation was not put in place. This placed patients at risk of harm. We raised concerns with the trust following our inspection, that needed immediate action. The trust completed retrospective incident reports for incidents that had occurred, safeguarding concerns were raised and police reports were completed where necessary. The trust also responded to sexual safety concerns by increasing staffing levels on the ward, facilitating community meetings to discuss sexual safety and discussed inappropriate behaviour with patients.

Staff reported incidents but managers did not ensure they were aware of the outcome. One member of staff told us lessons learned were shared via email. However, other staff were not clear how lessons learned were shared. Some staff members felt incidents were not dealt with, even when they were reported. Learning from incidents can help prevent recurrence.

Managers did not always ensure patients were given an apology when things went wrong. We requested duty of candour records for the last 6 months. We found the service were 61% compliant with duty of candour. For the incidents where duty of candour had not been completed, the trust told us that this related to individual circumstances such as advocacy being involved or the patient not wanting to engage in the process.Duty of candour training compliance was 100%. Duty of candour means health and social care providers must be open and honest about the care they give and use mistakes as opportunities to learn and improve.

Managers responded to complaints. We reviewed compliments and complaints for the last 6 months. There were 2 complaints in this time period. One complaint was related to management of the ward, staffing and physical healthcare. The second complaint related to staffing and risk of violence from other patients. We found that some action had been taken. Staffing was adjusted to ensure more male staff were on shift to manage the risk of violence.

Leaders shared lessons learned across the trust via a monthly newsletter. The Trust also shared 5 key messages, which included key information on areas such as safety alerts, safeguarding and patient safety.

We scored the service as 1. The evidence showed significant shortfalls. The service did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services

Managers did not ensure safe systems, pathways and transitions were in place. Admission procedures were not safe and essential information was not always received prior to admission. Some patients had been admitted to the ward without an assessment being completed, due to bed shortages and pressures on other wards. Staff told us they had concerns about patients being transferred to the ward without being assessed, as they had little knowledge of risks or how to manage them.

The trust had an operational policy in place, which outlined indications for referral to 439 Ipswich Road and the process to refer. The policy stated that referrals should be reviewed, screening assessments should be completed and multi-disciplinary discussions should be held prior to deciding if a patient was suitable for assessment. We found that this process was not always followed. There was not an exclusion criteria in place to identify risks that would be too high for the service to safely manage. Failure to assess and follow processes on admission puts patients at risk of avoidable harm.

We raised our concerns with the trust during our inspection and requested immediate action. The trust ensured that an assessment was completed with all patients on the ward. Some patients were moved to a more appropriate service.

Leaders had oversight of delayed discharges. Staff told us that planning for discharge started on admission to the ward. Staff told us some discharges were delayed, due to suitable accommodation not being available for patients.

Staff ensured external care workers were involved in patient care. For example, there were discussions with community care co-ordinators and other services. There was also a discharge and transfer policy in place. This is important for continuity of care.

We scored the service as 1. The evidence showed significant shortfalls. The service did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. They did not share concerns quickly and appropriately.

Managers did not protect patients from abuse. Safeguarding referrals were not made when sexual safety concerns had been identified. We raised this with the trust as an immediate concern and retrospective safeguarding referrals were completed. In addition, the trust referred themselves to safeguarding due to sexual safety incidents not being reported. Following our inspection, the trust facilitated community meetings at 439 Ipswich Road, where sexual safety was discussed with staff and patients.

Staff did not ensure all safeguarding incidents were logged. The safeguarding register did not include all safeguarding incidents that we identified. We reviewed the safeguarding register for 439 Ipswich Road and found 4 incidents of patients absconding, 4 incidents relating to sexual safety and 2 incidents of personal property going missing. On 2 occasions patients reported that money had been stolen and safeguarding referrals were not completed. This meant that patients were at risk of ongoing abuse.

Leaders did not ensure investigations in to safeguarding incidents were robust or effective. Investigations did not mitigate the risk of further incidents or support staff to learn lessons. We found that investigations did not lead to appropriate decisions being made to safeguard patients from abuse. Incidents had been resolved locally and safeguarding referrals had not been completed when necessary. Outcomes for some of the investigations had not been followed. For example, one investigation highlighted that staff needed to use supervision and coaching to manage safeguarding risks. We reviewed clinical supervision records and found that safeguarding risks had not been discussed. This meant that risks to patients were not being mitigated.

Managers did not ensure safeguarding processes were embedded. Not all staff knew who the safeguarding lead was for the ward. One staff member recalled when they had raised a safeguarding concern regarding a patient’s family. Other staff could not recall a time when they had needed to complete a safeguarding referral. Failure to embed safeguarding processes puts patients at risk of avoidable harm.

We asked 6 patients during our inspection if they felt safe on the ward. Two patients reported that they did not always feel safe. One patient told us about an incident of sexually inappropriate behaviour and belongings going missing. This was followed up with the trust and retrospective safeguarding actions were taken.

Managers ensured that safeguarding training was completed. Training compliance for safeguarding adults and children level 1 was 100% compliant and safeguarding adults and children level 2, including Mental Capacity Act and Deprivation of Liberty safeguards was 80%.

There was a global restrictive practice policy in place, which was last reviewed in September 2025. There were no incidents of restraint at 439 Ipswich Road.

We scored the service as 2. The evidence showed some shortfalls. The service did not always work well with people to understand and manage risks. They did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff did not always work with patients to understand their risk. Staff told us that 2 patients had been admitted to the ward without a risk assessment being completed. We raised this concern during our inspection and risk assessments were reviewed, however not in the presence of the patient. 4 risk assessments that we reviewed did show evidence of patient involvement and had been completed within 72 hours of admission. There were crisis management plans in place. Failure to involve patients in assessing risk means that essential information about risk is not being gathered. This puts patients at risk of avoidable harm.

There were no incidents of restraint, rapid tranquilisation or seclusion recorded over the last 6 months.

We scored the service as 1. The evidence showed significant shortfalls. The service did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

Managers did not ensure the environment was safe. The service had a ligature risk assessment that had been reviewed in November 2025. However, it did not cover current risk items in the garden that patients had access to. We were concerned that this placed patients at risk of avoidable harm

In the garden there were broken appliances, including a vacuum cleaner, televisions and a fan. The garden shed had a broken lock and inside were hose pipes and gardening tools. Staff had not identified these items as a potential risk to staff or patients. During our inspection we requested that the trust removed the appliances immediately for the safety of patients. Appliances were temporarily stored in a locked shed. Failure to identify and respond to environmental risks puts patients at risk of avoidable harm. The trust has now informed us that they have been safely disposed of.

There was no closed-circuit television (CCTV) in the main building or in the Coach House. There was CCTV covering some areas of the garden, however it did not cover the area behind the Coach House, where there were ligature risks. Mitigation for ligature risks was staff observations and checks

There were ligature cutters available in the main office however, there were no ligature cutters in the Coach House. The trust told us this was due to there being no staff lockable spaces within the Coach House. The trust told us that in the event of any incident, staff would respond with the grab bag and ligature cutters as per policy. We were concerned that if a ligature incident occurred in the Coach House or the garden behind the house, there would be a delay in staff accessing the ligature cutters to take immediate action to mitigate the risk.

There was a large hole in the garden fence that was large enough for a person to walk through. This had been reported to the trust in July 2025 and the hole was still there. We found 1 incident where a patient had absconded through the fence, and 2 other incidents where a patient had absconded where the garden fence was noted as a concern. A patient had also reported that this was a concern because they were having suicidal thoughts and were able to easily abscond. They added that the fence belonged to the neighbouring property. The lack of action from the trust to fix the hole in the fence placed patients at risk of avoidable harm. The trust has since informed us that the fence has been fixed.

During our tour of the ward, we found cleaning liquid in a paper cup within a kitchen cupboard in the Coach House. Whilst we acknowledge that patients have a level of autonomy due to the nature of the unit, this was not appropriately stored and put patients at risk of avoidable harm had it been ingested. We raised this with the trust during our inspection, and the cleaning liquid was immediately removed.

We found fire risks in the main building and in the Coach House. There was a tumble dryer and washing machine stacked in the laundry room of the main building. Directly behind the appliances there was a washing basket and a pillow, a potential fire risk. These items were moved on request. In the Coach House we found a black bin bag covering an emergency fire exit light. Staff told us the light was shining into patients’ bedrooms and therefore it had been covered with a black bag. Staff immediately removed this during our tour of the ward. Failure to mitigate fire risks puts patients at risk of avoidable harm.

Not all staff wore personal alarms to summon help if they needed it in an emergency. This was despite there being alarms in the service for them to use. We were concerned that this placed patients and staff at risk of harm.

Male and female bedrooms were not segregated on the ward. Staff told us that where patients had to share a bathroom, only the same sex shared. However, we had concerns about sexual safety on the ward.

The clinic room was locked when not in use. We found this was an area of improvement since our last inspection, where staff did not have access to a suitable clinic room. There was an examination couch, equipment for physical health checks and an emergency grab bag. Equipment was well maintained. For example, resuscitation equipment was available and was checked weekly by staff.

The premises was visited by a fire safety officer in August 2025, which reported that a satisfactory standard of fire safety was evident.

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

There was a ward manager, 2 deputy ward managers, 4 nurses and 11 healthcare assistants in post. At the time of our inspection the 2 deputy ward managers were on long term sick leave. Deputy ward managers were responsible for supervising some staff members and provisions had not been put in place to cover them while they were absent. This meant there was a lack of management oversight and staff were not receiving appropriate support.

There was an occupational therapy team and an activity co-ordinator at the service. A clinical psychologist was available for 1.5 days per week. Staff told us that patients had support from the clinical psychologist 1 day per week. The rest of the psychologist time was spent supporting staff. Staff told us there was not enough time for patients to receive support from the clinical psychologist.

Whilst there were 2 doctors available at 439 Ipswich Road they were only on the ward for 4 hours per week. Staff told us that patients did not have enough time to access a doctor. If patients needed to see a doctor out of these hours, staff told us they would go to a local GP or take patients to AE. Staff told us they could also contact a consultant at another service.

Managers did not ensure that staff were receiving appropriate support. Staff supervision and appraisal compliance was consistently low over the last 6 months. In September 46% of staff had received supervision and in October 72% of staff had received supervision. Staff appraisal compliance was also low and was 38% in October 2025. Leaders told us that staff sickness had resulted in a lack of support for some staff on the ward. The trust put an action plan in place to address low supervision and appraisal compliance. The plan included deploying Band 6 nursing staff from other services, scheduling all staff for supervision and overdue appraisals were to be prioritised. Failure to provide adequate supervision to staff could impact safety of patients.

Staff sickness was 13% in October and bank staff usage was 21%. Leaders told us that staff sickness had resulted in increased bank staff usage. No agency staff were used over the last 6 months.

Basic life support training compliance was 70%. However, training compliance for sexual safety, therapeutic engagement and supportive observation was 100%. Not all staff had completed medicines management face to face training. However, 100% had completed virtual training in medicines management. Staff told us they had regular training and had recently completed training in autism.

We found recruitment processes were safe. Staff had disclosure and barring service (DBS) checks in place.

We scored the service as 2. The evidence showed some shortfalls. The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

Managers did not have robust infection prevention and control procedures in place in all areas of the ward. Prior to our inspection we had received information of concern about the cleanliness of the ward. During the inspection we found that some areas of the ward were not clean or well maintained. We observed mud in the entrance and stairwell of the Coach House. Bedrooms and bathrooms in the Coach House were not always clean. We observed a dirty bathroom and bedroom cluttered with rubbish. Patients told us that they liked to clean their own bedrooms, whilst others preferred the cleaner to clean their bathrooms.

We acknowledged the improvements with the clinic room since our last inspection. There was an identified clinic room, which was clean and well maintained with the required equipment. Staff had completed training in infection prevention and control level 2 and compliance was 100%. Patients did not raise any concerns about the cleanliness of the ward while we were on-site.

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning.

Prescribers did not ensure that prescriptions were always specific. We found that one patient had been prescribed as required insulin. Their prescription chart did not state the exact blood sugar levels that were needed and could result in administration error. We did not see any evidence of medication errors, as a result of this, on the incident log.

The medicines cupboard and fridge was in good order. All medicines were in date and fridge temperatures were monitored daily. Controlled drugs were stored safely. There were emergency drugs present, including naloxone in case of an opiate overdose and flumazenil in case of a benzodiazepine overdose.

There was consent to treatment in all records reviewed. As required medication had been reviewed in the last 14 days and medicines prescribed were all within the correct limits.

We reviewed 10 medication charts and found that allergies had been recorded, prescriptions were signed by a doctor, and medicines were within British National Formulary limits.