- 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 17 June 2026
Contents
Ratings - Acute wards for adults of working age and psychiatric intensive care units
Our view of the service
Ardleigh Ward, located at The Lakes, Colchester Hospital, is provided by Essex Partnership University NHS Foundation Trust. The ward is an 18-bed acute inpatient service for female patients.
The hospital is registered with the Care Quality Commission to carry out the following regulated activities:
• Treatment of disease, disorder or injury
• Assessment or medical treatment for persons detained under the Mental Health Act 1983
The Care Quality Commission last inspected this location in July 2025 where the service was rated as Requires Improvement. We found 1 breach of the legal regulation 12, safe care and treatment, Health and Social Care Act regulations (2008).
We inspected the service in January 2026, the report for this inspection will be unrated and the ratings reflect the previous inspection only.
Our View of the Service
We carried out an inspection on the 21st of January 2026 due to receiving information of concern about safe staffing and high levels of self-harm on the ward. At this time there were 18 patients admitted to the ward.
At this inspection we found 3 breaches in relation to Regulation 12: safe care and treatment, Regulation 18: staffing and Regulation 20: good governance. Due to the serious concerns we found, we wrote to the trust and requested immediate actions. The trust were able to show how they had mitigated immediate risk to patients.
Staff did not respond appropriately to ligature alarms, and staff raised concerns at lack of support due to low staffing numbers.
One patient did not have a comprehensive risk assessment or appropriate planning for physical health care recorded.
Staff observed patients for more than the recommended time of 2 hours. This does not comply with best practice guidance.
Staff did not ensure the environment on the ward was safe for patients. High risk items that patients could harm themselves with, for example a bottle lid and a towel were discarded in a communal area. One patient’s bedroom was extremely unkempt and included high risk items such as plastic bags and empty bottles.
Staff raised concerns at the lack of time allocated to them to complete administrative tasks, this included the recording of incidents and performing comprehensive handovers.
Staffing met establishment numbers; however, this was not meeting the needs of the ward. Staff told us staffing numbers did not always make them feel assured they could provide safe care to patients with the current establishment. Patients told us that they felt they did not get the care they needed unless they were on enhanced observations.
Bank staff were not always willing to work on the ward due to the high acuity and complex needs of the patients, and the perceived risks should something go wrong. This led to further staff shortages.
Staff told us they felt burnt out and the ward felt unsafe.
Mental Health Act and Mental Capacity Act Compliance
Mental Health Act
The service admitted patients under the Mental Health Act 1983.
Staff received and kept up to date with training on the Mental Health Act. Training was mandatory for staff, and the compliance rate for registered staff was 86% and 92% for unregistered staff.
Staff had access to support and advice on implementing the Mental Health Act and its Code of Practice. Staff could receive assistance from the Mental Health Act team at the trust, and the mental health act office provided training for all staff.
The service had clear, relevant and up-to-date policies and procedures that reflected all relevant legislation and the Mental Health Act Code of Practice.
Staff did not always record regular explanations of patients’ rights, under the Mental Health Act. We looked at 6 care records and in 1 there was no record of the patient having their rights explained. In another there was 1 recent record, but nothing in the previous 6 months. Two care records showed patients’ rights being regularly explained and 2 informal patients were having their rights explained to them regularly.
We were not provided with requested data regarding Section 17 (S17) leave and any occasions when the prescribed leave had not taken place. S17 leave (Mental Health Act 1983) allows patients detained in a hospital for mental health treatment to take authorised temporary leave from the ward.
Mental Capacity Act
Staff received and kept up to date with training in the Mental Capacity Act and had a good understanding of the 5 principles. Training on the Mental Capacity Act was incorporated into the safeguarding adults and children training and was mandatory for staff. At the time of inspection, the compliance rate was 92% for level 2 and 93% for level 3.
Staff did not complete an assessment of each patients’ capacity to consent to admission and treatment on admission. We looked at 7 care plans and 1 showed a record of an assessment taking place. There was no record of capacity assessments in the other 6 care plans we looked at.
People's experience of this service
We spoke with 8 patients during the inspection. Some patients did not feel safe on the ward. Patient concerns included low staffing, observations not being completed properly and staff not engaging with patients. They also raised slow responsiveness to incidents, including self-harm, and fear of violence and aggression from other patients. We spent time observing daily life and routines to help us to understand their experiences. Staff did not always interact with patients whilst on 1:1 observations, however we did see some patients engaging in art therapy throughout the day.
A patient told us they had been repeatedly assaulted by another patient. They told us that staff do not address physical violence. Another patient told us that staff laughed at them during a restraint in which the patient had been injured.
A family member told us they did not feel their loved one was receiving good care and described staff as ‘unprofessional’. They were concerned the ward was always short staffed and raised concerns at a lack of appropriate visiting areas on the ward. However, they had received a response from the service when raising concerns and told us they attended ward rounds and the doctor was good, positive and explained things to them and the patient.