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

This means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm. All wards 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 used systems and processes to safely prescribe, administer, record and store medicines. The service managed patient safety incidents well.

This service scored 72 (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. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Staff knew what incidents to report and how to report them. Staff reported incidents clearly in line with the trust’s policy. Staff recorded incidents on an electronic incident reporting system. All incidents were reviewed by the ward manager. Staff understood duty of candour. They were open and transparent and gave young people and families a full explanation when things went wrong.

The service had up to date incident reporting processes. Governance processes showed leaders had oversight of incidents and took action to manage risks.

Staff were de-briefed and received support after an incident. Staff met to discuss learning from incidents which was shared in a variety of ways. Staff told us they received regular communication about learning from incidents. If an incident took place on the ward, it would be discussed at handover. Staff received feedback from the investigation of incidents. They met to discuss this feedback, review lessons learned and continually identified and embedded good practice.

Managers investigated incidents thoroughly and were able to give examples of learning from recent incidents. Managers reviewed incidents and identified any themes or trends. Information from these discussions were reported up to clinical governance meetings. Managers reviewed lessons learned, issues requiring support to resolve and areas of good practice in clinical governance meetings.

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

The wards admitted young people aged between 13 and 18 years old. Young people were admitted for a range of mental health difficulties, including depression, self-harm, anxiety and psychosis. All young people admitted to Larkwood were detained under the Mental Health Act. Before admission staff held professionals’ meetings where risks and needs were discussed. The multi-disciplinary teams met to discuss new referrals to ensure they could meet the needs of the young person and maintain the safety of all young people on the ward.

Staff involved all the necessary health and social care services to ensure young people had continuity of safe care, both within the service and post-discharge. Other agencies involved with young people’s care were invited to attend ward rounds and could attend virtually if that was preferred.Staff involved commissioners, care co-ordinators, social workers and the community mental health team.

Staff ensured that young people’s discharge from the service was managed safely. Discharge planning began at the point of admission. Staff liaised with the appropriate services to ensure robust discharge plans were in place. We looked at 7 care plans. Young people had a discharge plan, which was discussed in meetings and was regularly updated.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. 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. The service shared concerns quickly and appropriately.

Staff received and kept up to date with safeguarding training appropriate for their role. Staff compliance with safeguarding adults’ and children level 3 training was 100% on Poplar Unit, 95% on Larkwood and 92% on Longview. Safeguarding leads were identified within the service and there was an overall safeguarding lead for the trust.

Staff knew who to inform if they had a safeguarding concern. Staff could give examples of how to protect young people from harassment and discrimination, including those with protected characteristics under the Equality Act. Staff gave us examples where they had raised safeguarding concerns.

Staff knew how to recognise young people at risk of or suffering harm and worked with other agencies to protect them.

Children were not permitted to visit young people on the wards. Visits from children took place at other areas in the hospital.

There were clear procedures in place to promote young people’s safety. The safeguarding adults and children's policies provided guidance to ensure staff were aware of how to raise a safeguarding concern. Noticeboards in the ward offices also provided contact details for the local safeguarding authority, as well as who the safeguarding leads were.

Staff could recognise signs when young people experienced emotional distress and knew how to support them to minimise the need to restrict their freedom to keep them safe. Young people were restrained only where necessary and for the minimum period. Staff made every attempt to avoid using restraint by using de-escalation techniques and restrained young people only when these failed and when necessary to keep the person safe. Staff understood the Mental Capacity Act definition of restraint and worked within it.

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. Staff assessed and managed risks to patients and themselves well and followed best practice in anticipating, de-escalating and managing challenging behaviour. Staff used restraint and seclusion only after attempts at de-escalation had failed. The ward staff participated in the provider’s restrictive interventions reduction programme. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff made sure young people’s care plans were up to date. Staff involved young people in care planning. Some young people were offered and accepted a copy of their care plan. Young people were given the opportunity to participate in review meetings about their care. Care plans were personalised to the individual.Staff completed a risk assessment of every young person on admission and updated these regularly, including after any incident. We reviewed 7 care records and saw staff used recognised risk assessment tools to assess young people on admission. Staff updated these regularly and following any incident.

Staff identified changing risk levels and amended observation levels and interaction with young people in response. Staff followed trust policy on the use of observation and searching, and staff discussed levels of observation with the multidisciplinary team.

Staff we spoke with showed a good understanding of the management of risk and reducing restrictive interventions. Staff spoke about using restraint and seclusion as a last resort and examples of interventions they would use to manage and de-escalate situations.

Compliance with Therapeutic and Safe Interventions training (TASI) was 97% on Larkwood and Poplar, and 90% on Longview. Staff also completed patient safety level 1 training, compliance was 97% on Larkwood and Longview and 100% on Poplar Unit.

The trust had a reducing restrictive interventions policy which included guidance and procedures for managing and reducing restrictive practice. The trust held monthly restrictive practice group meetings, we reviewed the minutes from these meetings, where all areas of restrictive practice were presented. People we spoke with said they felt safe on the ward and that restrictions on the ward made sense.

We scored the service as 2. The evidence showed some shortfalls. The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

The ward areas were clean and well equipped. Staff regularly reviewed the environment, identified and managed ligature risks, and mitigated risks quickly to keep young people safe. Managers ensured staff on the wards had easy access to information on environmental risks, this included a map of hotspot areas. The service completed ligature point and blind spot audit tools, covering all areas of the wards and external areas. Managers also carried out, ward environmental checks; findings were then taken to clinical governance meetings to be actioned.Staff we spoke with knew about any potential ligature anchor points and knew where ligature cutters were located. Staff could describe mitigations taken to reduce risks to young people’s safety.

The wards were mixed sex; there was a male corridor and female corridor on each ward. The corridors to bedroom areas were kept locked and young people required staff support to access them, managers said this was for safety reasons and the trust were exploring options that would enable young people to access the corridors freely where risk assessed to be able to do so. Each person had their own bedroom, which they could personalise. Young people had a secure place to store personal possessions.

The ward had a range of rooms and equipment to support treatment and care. The ward had quiet areas young people could use. The service had a room’s where visitors could come and meet young people.

Seclusion rooms allowed clear observation and two-way communication and had toilet facilities and a clock.

Staff could not observe young people in all parts of the ward. This risk was identified and recorded within the ligature risk assessment and mitigated using convex mirrors, CCTV and staff observations. At the time of our inspection compliance for preventing suicide by ligature training was 89% on Larkwood, 93% on Longview and 97% on Poplar Unit.

The wards used CCTV in communal areas and could use this to review safety incidents.

Staff had easy access to alarms and young people had easy access to nurse call systems.

The service had policies to follow fire and safety practices on site. There was a fire escape plan and fire action notices on the ward which showed the assembly point.

Clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly.

On the day of our first visit to Larkwood ward, we were informed that the washing machine was not working and young people did not have access to the sensory room as a piece of the carpet had been pulled up. On our second visit to Larkwood, young people told us that the washing machine had not yet been fixed and they were having their washing done on Longview ward. Young people said this resulted in items getting mixed up and on some occasions been returned unwashed, young people also said that they still did not have access to the sensory room.

We scored the service as 3. The evidence showed a good standard. The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The service had enough nursing and support staff to keep young people safe. Leaders had calculated the number and grade of nurses and healthcare assistants required based on people’s needs.

The service used regular bank staff where needed. Over the last 3 months the number of shifts filled by bank or agency staff was 31 on Larkwood, 271 on Longview and 340 on Poplar. Leaders told us this was due to sickness, annual leave, training, and vacancies. When bank staff were used, they had received the trust induction and training and were familiar with the ward, staff and young people.

For the last 12 months, staff turnover for Poplar Unit was 6.13% Longview 8.26% and Larkwood 2.66% - this was below the trust target of 12%. The service had a low staff sickness rate of 4.89% for Poplar Unit, 2% for Larkwood and 3.05% for Longview in January 2026 - this was below the trust target of 5%.

Staffing levels allowed people to have a regular one-to-one time with their named nurse. Throughout the inspection we observed enough staff on the ward to facilitate activities.

There were enough staff to carry out physical interventions and observations safely and staff had been trained to do so.

There was adequate medical cover day and night, and a doctor could attend the ward quickly in an emergency. The service operated an out-of-hours rota for doctors.

Staff had received appropriate mandatory training. Staff compliance with mandatory training was between 80% and 100%, this was due to sickness and a new staff joining.

The mandatory training programme was comprehensive and met the needs of people and staff. Leaders monitored mandatory training and alerted staff when they needed to update their training.

The service had access to a range of specialists to meet the needs of people on the ward. The service employed a matron, ward manager, deputy ward manager, doctors, nurses, healthcare assistants, psychologists and occupational therapists.

All staff attended the trust induction programme and shadowed experienced staff before they were fully incorporated into the staff numbers.

Leaders supported permanent staff to develop through yearly, constructive, comprehensive supervisions and appraisals of their work. At the time of our inspection, compliance for supervisions was 90.70% on Poplar Unit, 100% on Larkwood and 97.56% on Longview.

Leaders recognised poor performance, could identify the reasons, and managed these.

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The ward areas were visibly clean and tidy. The ward kept up-to-date cleaning records that demonstrated that the ward area was cleaned regularly. Staff maintained equipment well and kept it clean. The service followed their infection control policy, including hand washing. The service carried out monthly infection prevention and control audits, which included checks on personal, protective equipment (PPE), handwashing, equipment, cleanliness and mattresses. Audits showed Poplar Unit was 89% compliant, Larkwood 93% and Longview 93%.

People and carers told us the wards were clean and tidy.

Staff completed Infection, Prevention and Control training. Compliance was 100% across the 3 wards.

The trust had a detailed Infection Prevention Control policy, which was reviewed regularly. A policy ‘at a glance’ with staff responsibilities was also available.

We scored the service as 3. The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

There were systems and processes in place to manage medicines safely. Medicines including Controlled drugs (CDs) were stored and recorded in line with legal requirements. Access to medicines storage areas was limited to authorised staff only. Staff completed daily ambient room and fridge temperature checks. Liquid medicines had opened and expiry dates. Staff had access to emergency medicines.

Young people’s physical health was monitored. This supported safe prescribing. Ward doctors completed electrocardiograms (ECGs) and blood tests on admission and when needed. Staff used the National Early Warning Score (NEWS2) and escalated concerns promptly. Venous thromboembolism (VTE) risk assessments were completed on entry.

Staff used Dialectical Behaviour Therapy techniques (DBT is a form of cognitive behavioural therapy which can support people expressing distress and agitation) and “DBT prescriptions” tailored to each young person before medicines were administered. Use of rapid tranquilisation (RT - injectable medicines used to rapidly reduce acute agitation or distress) was low on the ward. When RT was required, staff offered oral options first and completed post‑dose checks after any RT administration. Where full observations were declined, staff recorded respiratory rate and level of consciousness.

Medicines reconciliation (the process of confirming an accurate list of current medicines) took place on admission. Pharmacy support was available both in person and out of hours via an on-call service. Same‑day medicine supply was available from the pharmacy department on request. A small stock of to‑take‑out (TTO) medicines supported timely leave for informal patients. Staff adjusted administration times to meet individual needs where appropriate. Staff were trained and competent, supported by a band 6 training lead. They completed Oliver McGowan training and demonstrated awareness of STOMP/STAMP (Stopping Over‑Medication of People with a Learning Disability, autism or both / Supporting Treatment and Appropriate Medication in Paediatrics). Information was accessible through Choice and Medication leaflets and interpreters. Young people were involved in decisions through weekly multi‑disciplinary team (MDT) meetings.

On the Electronic Prescribing and Medicines Administration (EPMA) system, some ‘when required’ (PRN) prescriptions lacked a clear indication of when it should be used. Records of PRN use did not always show the reason or if it had been effective, particularly for night‑time promethazine. Several Mental Health Act (MHA) consent to treatment forms used broad wording such as “for emergency use” for sedative or anti-anxiety when required medicines [PRNs]. This created ambiguity where medicines were used for sleep rather than agitation or anxiety. Medicines to aid sleep would not be considered an emergency use. Staff did not use any recognised side effect rating scales when monitoring side effects. These can help to identify and monitor adverse reactions from prescribed medicines.