Essex Partnership University NHS Foundation Trust

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• 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 requires improvement. At this assessment the rating has changed to good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care. Leaders had the skills, knowledge and experience to perform their roles. Staff knew and understood the provider’s vision and values and how they applied to the work of their team. Staff felt respected, supported and valued. Governance processes operated effectively. Performance and risk were managed well. Teams had access to the information they needed to provide safe and effective care. Staff collected analysed data about outcomes and performance. They used this to identify improvements.

This service scored 75 (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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Staff felt respected, supported and valued. They said the service promoted equity and diversity in daily work and provided opportunities for development and career progression. They could raise any concerns without fear.

Staff knew and understood the trusts visions and values and how they were applied in the work of their team. Staff had the opportunity to contribute to discussion about the strategy for their service, especially where there were changes being made to the service. Young people and carers were involved in decision making about changes to the service. The senior leadership team had communicated the vision and values to staff and young people who used the service.

Leaders were aware of any risks to delivering their strategy and local action plans to address that they monitored and reviewed these for progress.

We scored the service as 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. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Staff and young people told us that leaders were visible on the ward, approachable and engaged well with them. Managers said they received good support from senior leaders. Leaders were visible within the service and had the experience, capacity, capability, and integrity to ensure that the organisational vision could be delivered, and risks were well managed.

Senior leaders were skilled, experienced and knowledgeable. Experienced leaders had a strong understanding of the service they managed. They were aware of the service performance and aware of challenges faced by the service. They collaborated with one another and other staff to develop solutions or mitigations and were supported by management at provider level.

We received feedback from partners, who said senior leaders were visible, compassionate and held the needs of young people, their families at the centre of what they did, their experience of senior leaders were that they were honest, transparent and practiced with integrity.

Leadership development opportunities were available, including opportunities for staff. Leaders completed the Management Development Programme, which had been developed for all line managers, ranging from bands 4 to Associate Director, the programme was mandatory for all new leaders joining the trust.

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

Staff were aware of the term ‘freedom to speak up’ and what this meant, they were able to explain how they would access freedom to speak up information if they needed it. Staff said they felt confident in speaking up and raising concerns, felt listened to and where there was learning this was shared amongst staff.

The trust had policies in place that were in line with best practice guidance for freedom to speak up, whistleblowing and complaints. Between 1 November 2025 and 1 March 2026 there had been 4 freedom to speak up concerns raised. The themes were processes around booking bank and agency staff, and staff having to support other roles, these had all been escalated to the care unit leadership and were being managed. Staff were given the opportunity to speak up and drive improvement through staff surveys, supervisions and meetings.

Young people had the opportunity to provide feedback about the service. They knew how to raise concerns and received a response. Staff facilitated regular community meetings on the wards, which gave young people the opportunity to give feedback and receive updates about progress or changes following their feedback.

We scored the service as 3. The evidence showed a good standard. The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

The trust had 5 staff equality networks where members worked with the trust to understand the needs of the communities and shape improvements. These networks were Ethnic Minority and Race Equality, Gender Equality, LGBTQ+, Disability and Mental Health, Faith and Spirituality. Feedback from staff, patient surveys, equality networks and data from the Workforce Race Equality Standards (WRES) and Workforce Disability Equality Standard (WDES) were used to inform trends.

Leaders had ensured reporting of racial abuse against staff was prioritised. The trust had added the category of racial abuse to the incident reporting system so that staff were able to report racial abuse and this was monitored. When reviewing incident records, we saw evidence that incidents of racial abuse were being reported.

Staff had access to the Resilience, Intelligence, Strength and Excellence (RISE) programme, a talent development programme aimed to improve Workforce Race Equality Standard (WRES) indicators. The programme was targeted towards Black and Ethnic Minority staff to enhance their career progression.

Staff undertook diversity and inclusion training annually. Staff we aware of information available on the intranet relating to equality and diversity.

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

Leaders attended regular governance meetings for safety, audit, quality and governance. The service discussed and addressed key areas of performance, risk, audit, culture and workforce. Minutes showed areas of concern were identified and actions taken to learn and improve. They also included actions, and progress was updated.

The trust held a risk register for specialist services which we reviewed. All risks were identified with risk scores, controls, mitigations with assurance and action review dates. Leaders said staff could make suggestions to add to the risk register which would be escalated to the quality assurance meeting.

Leaders completed regular audits on the ward, these included, matron audits, ward manager audits and person-centred care audits. Staff undertook or participated in local clinical audits. The audits were sufficient to provide assurance and staff acted on the results when needed.

Managers had access to information to support them with their management role. This included information on the performance of their wards, staffing and patient care. The electronic system used by the service allowed managers to have access to information such as whether care plans, physical health checks and legal status were up to date. They also had access to information on staff training compliance. Service performance was discussed in clinical governance meetings.

Staff said they had regular team meetings, situation report meetings to discuss any issues or risks, multidisciplinary team meetings, attended safety huddles, received regular lesson learned information and understood their roles. Staff felt the wards were well organised and managed. Staff were able to give examples of the checks they had participated in to ensure the safety of the wards such as security checks, observations, audits and checks of equipment.

Leaders explained how they communicated and interacted with staff to ensure they managed risk and sought staff views to make improvements. Leaders spoke about their responsibilities in relation to maintaining oversight of the services, by being present and ensuring they had managers and matrons on site.

Staff knew how to deal with complaints and reported incidents and safeguarding concerns. Leaders shared lessons learned from investigating complaints, incidents and safeguarding issues.

The service had plans for emergencies – for example, adverse weather or an outbreak of illness. The hospital had a business continuity plan in place for all wards. The plans identified the process to be followed in the event of several different emergency scenarios.

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

The service worked well with other agencies, there were established relationships between specialist services, the matrons and the ward managers liaised regularly to share information and good practice.

The services had appropriate processes in place to support effective links with the community and with partners. Feedback we received from partners was positive, partners said they valued their relationship with EPUT and the willingness to collaborate to ensure young people received the care they needed, they explained being governed within different trusts can present barriers, and this collaboration had proved essential in overcoming these and maintaining a focus on delivering and improving quality care for young people.

Staff invited family members and external professionals to meetings so they could discuss any issues and receive any updates about people’s / their family member's care and treatment.

Staff had access to regular team meetings on the wards. Staff were able to propose, exchange and discuss ideas in terms of good practice. Staff could attend reflective practice sessions facilitated by the psychology department.

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

The trust had 5 key messages that were shared with staff monthly, these were on the intranet. The service also kept a copy in the culture of learning folder, and we saw evidence of these messages being discussed in team meetings. The trust also sent out learning alerts, these included what happened, identified learning and actions required with a time frame for completion.

The trust had a lessons identified newsletter, this included learning from deaths, complaints, compliments and patient safety incident management.

Staff that we spoke with said leaders listened and considered any ideas staff shared with them for improving the service or about concerns around people’s care.

The service was part of the Quality Network for Inpatient CAMHS (QNIC). QNIC was a program run by the Royal College of Psychiatrists, it reviewed and accredited child and adolescent mental health inpatient services. The ward hosted reviewers, attended reviews of other services and shared learning and best practice across services.