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

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 as good. At this assessment the rating has changed to requires improvement. The trust was in breach of regulation 17 (good governance).

Leaders did not have effective or robust governance procedures in place to monitor and identify areas for improvement. Managers did not have good oversight of staff’s compliance with supervision or ensure there were enough senior staff to provide the supervision. Managers had not address the gaps in clinical audits. Failing to do this meant that they had not identified areas for improvement within the service. Managers did not have adequate systems in place to monitor the assessment of risk or robust oversight of incidents. Concerns relating to the safety of the environment were not effectively managed.

Staff told us that senior leaders were not visible, and they did not always feel supported. This meant there were widespread and significant shortfalls in service leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

There was a business continuity plan for unplanned events, such as a fire. There was a freedom to speak up policy in place and the trust had a strategic plan.

This service scored 39 (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 shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities.

Managers did not create a culture based on transparency. We found that staff did not always report concerns to appropriate managers because they did not believe action would be taken. Staff raised concerns with leaders, however appropriate actions were not always taken. Staff told us they did not always receive feedback from leaders following an incident. Closed cultures put patients at risk of abuse and avoidable harm.

The trust were completing a review and re-design of 439 Ipswich Road led by the Integrated Care Board (ICB). This was to focus on ensuring a 6-month rehabilitation programme was in place and that there were robust system links to the wider community, including accommodation and move on pathways. Within the review and redesign, the service specification was also due to be reviewed. However, staff did not feel supported by leaders with the review and re-design. This was having an impact on morale.

Essex Partnership University NHS Foundation Trust had a strategic plan in place. Their vision was “To be the leading health and wellbeing service in the provision of mental health and community care." Strategy development included a review of policy, engagement with service users, reviewing service level demand, identifying challenges and multi-disciplinary review.

The trusts values were “We care, we learn, we empower,” which was communicated in the trust’s strategic plan. Staff were able to explain the care they were offering to patients.

We scored the service as 1. The evidence showed significant shortfalls. The service did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.

Leaders did not adequately support staff. Most staff we spoke with felt that managers at 439 Ipswich Road were approachable but there were times where staff felt they could not raise concerns. For example, a staff member did not raise an incident with a manager because they did not believe action would be taken. Failure to act on concerns puts patients at risk of harm.

Some staff told us senior leaders were not visible and there was little support. For example, the service was due to have a re-design and staff told us that senior managers were not supporting with this. This was having impact on morale within the team.

We scored the service as 2. The evidence showed some shortfalls. People did not always feel they could speak up and that their voice would be heard.

Leaders did not create a positive culture where staff felt they could speak up. Staff raised incidents with managers but were not told what action was taken. Staff raised concerns via alternative routes because they did not feel they would be listened to. For example, one staff member raised a concern with a leader from another service. Another staff member used the Freedom to Speak Up Guardian to raise concerns.Failure to create an open culture for staff to raise concerns can put patients at risk of harm.

Patients were able to give feedback in community meetings and there was a suggestion box on the ward. We raised concerns about sexual safety on the ward. Following this, community meetings were held and sexual safety on the ward was discussed with patients.

There was a freedom to speak up policy in place, which explained the rights and responsibilities of staff when raising an issue or concern.

The trust had not received any feedback from patients or carers through iWantGreatCare, a health review website.

We scored the service as 2. The evidence showed some shortfalls. The service did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Managers did not always promote and inclusive and fair culture. Some staff told us that it could be difficult to get adjustments made where needed and there was a poor culture at 439 Ipswich Road. This had an impact on morale.

We did find there was some support in place for staff members with additional needs. For example, a staff member had a support worker to enable them to undertake their role.

We scored the service as 1. The evidence showed significant shortfalls. The service did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Leaders did not always identify actions from investigations to keep people safe. Investigations were completed but immediate actions were not always identified. Where actions had been identified, they were not always completed. For example, supervision was not completed with a staff member, where it had been identified as an action following an investigation. Failure to identify and implement actions following an investigation puts patients at risk of ongoing abuse and avoidable harm.

Whilst leaders completed environmental audits of the environment they failed to identify all the risks and did not mitigate risks they did find. Leaders did not identify immediate risks to patients and had to be prompted to make the environment safe. Further environmental risks were seen as a low risk to patients and were not immediately rectified. For example, a hole in the garden fence had been reported as a safety concern by a patient. This was not immediately fixed. Whilst informal patients should be free to leave the ward as requested, at the time of our assessment there were patients on the ward who were detained under the Mental Health Act, for whom leave must be appropriately authorised.

Leaders did not have adequate processes in place ensure that patients had risk assessments in place to keep them safe. Staff raised concerns that patients were inappropriately placed at 439 Ipswich Road due to bed shortages. Leaders took no action to address these concerns. Due to this inaction staff were not aware of individual patient risks and therefore were not able to appropriately mitigate them. This put patients at risk of avoidable harm.

Managers failed to ensure that staff had access to regular clinical supervision. Supervision compliance from May 2025 to October 2025 was 46%. Whilst managers were monitoring compliance, they failed to take action to improve staffs’ compliance with supervision. Therefore, managers could not be assured that staff were upholding standards, developing competence and receiving emotional support.

Leaders did not have good oversight of governance processes. We reviewed audits that were completed at the service. While some audits were regularly completed, others were not always completed as required. For example, the prescribing medicine and administration chart audit was 60% compliant in November. In October there was no evidence that this audit had been completed. The requirements were for this audit to be completed weekly. Ward manager audits were due to be completed monthly. In the last year 4 audits had been completed. This meant that some safety issues may have been undetected.

Managers did not provide adequate support and did not have adequate oversight of staff. Supervision compliance was an average of 46 % from May to October 2025. Investigations identified supervision as a process to address individual concerns with staff. Issues identified were not raised in supervision with staff when needed. Leaders could not tell us how some concerns were addressed with staff. This put patients at risk of ongoing abuse and avoidable harm.

There was a clear framework for business meetings. For example, where gaps in training were identified this was discussed with the team.

There was a business continuity plan in place which was last reviewed in September 2025, which gave details of appropriate contacts and a plan for events that could have an impact on the running of the service.

We scored the service as 2. The evidence showed some shortfalls. The service did not always understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

Leaders did not always work in partnership with safeguarding authorities. For example, safeguarding referrals and concerns were not always shared where necessary. However, leaders collaborated with partners regarding the review and re-design of 439 Ipswich Road. This included engagement with stakeholders, such as integrated care boards and the local authority.

We scored the service as 2. The evidence showed some shortfalls. The service did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

Leaders did not always focus on continuous learning, innovation and improvement. The trust shared 5 key messages monthly with staff to improve quality of care and a lessons learned newsletter. However, staff were not always able to tell us how lessons learned were shared. This means that lessons learned were not embedded.

The ward did not participate in accreditation schemes.