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.

The trust were in breach of regulation 12 (safe care and treatment), regulation 18 (staffing) and Regulation 17 (Good governance).

Managers did not ensure the ward was safe. We observed staff failing to respond to incidents appropriately, including a failure to respond to ligature alarms. Staff reported a lack of support available to them on the ward when incidents occurred. They were not always allocated time to complete administrative tasks such as comprehensive handovers and the recording of incidents. This increased the risk of avoidable harm and prevented thorough risk assessments and learning from incidents.

Managers did not ensure that care records and risk assessments were updated after serious incidents, compromising the physical health of patients. Failure to risk assess, safeguard and learn from incidents puts patients at risk of ongoing and avoidable harm.

Managers allocated staff to complete enhanced observations for more than 2 hours consecutively, failing to comply with best practice guidance and exposing staff to tiredness and a lack of vigilance.

Leaders did not ensure that the environment of the ward was safe. Items that could be used by patients to cause harm to themselves or others were identified in communal areas, increasing risk of harm to patients. This included a discarded dirty towel on the floor in a communal area and access to bottle lids on the ward. One patient’s room was extremely unkempt and messy and contained high-risk items such as plastic bags and empty bottles, posing a risk of avoidable harm.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Learning Culture
There were 5 serious incidents recorded on the ward in the last 12 months, these included 2 incidents of self-harm including 1 of serious self-harm and 3 episodes of a patient going absent without leave (AWOL). Staff had not recorded a serious incident in the serious incident log that we saw whilst reviewing care records. Staff had not recorded a risk assessment, learning or actions recorded in relation to this.
We spoke with 11 members of staff; all knew what incidents to report and how to report them. However, we were told that due to low staffing numbers on the ward and lack of time provided by leaders to complete administrative tasks, incidents were not always recorded.
Staff completed a SWARM huddle where insights, reflections and learning took place after a serious incident of self-harm.
Staff understood the duty of candour.
 

Safe Systems, Pathways and Transitions

The service had a clear admission policy that provided clear responsibilities to staff that would assess the placement, including the Home Treatment Team and Approved Mental Health Act Practitioners. The policy stated that a trauma informed approach was taken and the views of the person and family members were considered before deciding on admission. It included a clear pathway for people that were to be admitted to inpatient mental health wards.

We sought feedback from commissioners and external partners, however, none of them responded to our request.
Staff planned patients discharge planning from admission which was reviewed regularly.
Staff made appropriate referrals, including working with the acute hospital when a patient was transferred there. We also saw partnership working with discharge coordinators, community mental health teams and crisis teams.
 

Safeguarding

The service had a safeguarding policy and clear processes in place for staff to follow. Staff received training on how to recognise and report abuse, appropriate for their role. All staff completed mandatory safeguarding training modules and compliance was between 92% and 100%.

The trust had a safeguarding lead, and other staff undertaking safeguarding roles. Ward staff knew how to raise safeguarding concerns. In the previous 3 months staff had made 14 safeguarding referrals. Safeguarding concerns related to a variety of incidents including sexual safety and neglect. One safeguarding incident was observed by an external visitor whilst a patient was on 1:1 observations and not seen by observing staff whose attention was elsewhere. The patient was able to self-harm requiring urgent physical health care.

The safeguarding team tracked the recording of safeguarding referrals, including actions taken.

Staff followed safe procedures for children visiting the service. Children were not allowed on the ward. At the time of inspection, the family room was unavailable due to refurbishment so children could only visit off the ward.

Staff provided a patient with a prohibited item leading to an incident that subsequently required surgery.

A safeguarding had been raised due to staff arguing in front of patients who tried to intervene. These matters exposed patients to an increased risk of serious harm and did not provide a safe or therapeutic environment for patients.

Involving People to Manage risks

We looked at 7 care plans and risk assessments. All patients had a risk assessment completed at admission. There were gaps in patient assessments including physical health assessments and management plans.
Incidents and risk were not always integrated into care plans, and incident numbers were not always present preventing cross referencing to enable ongoing risk assessment. Risk assessments did not show family involvement and patient input was not consistent throughout the records.
Care plans were not all up to date and were not reviewed on a regular basis and not all patients had a current care plan. One did not reference psychology or occupational therapy involvement and had no medication care plan.
There had been 21 incidents of restraint between 1st November 2025 and 31st January 2026. No incidents involved prone, face down restraints. There were 2 incidents of long-term segregation, and Rapid Tranquilisation was used 11 times during the same period. There was a restrictive practice policy in place noting individual, ward/unit and trust wide responsibilities.
All patients had access to an Independent Mental Health Advocate (IMHA) during their stay at the hospital. Information about how to access the advocate was displayed around the ward.
Staff did not provide regular opportunities for patients to feedback about the service. Due to staff shortages and time pressures, community meetings had not been held regularly.
 

Safe environments

Managers did not ensure that regular assessments of the ward environment were completed. High risk items such as a discarded towel and a bottle lid on were on the ward that could be used by patients to self-harm. This exposed patients to an avoidable risk of harm.

We toured the ward and observed that it was mainly clean. A room provided for patients to get hot drinks was dirty, and rubbish had been discarded where there was no bin available. A bathroom and 2 toilets were also not clean, with 1 having an overflowing bin.

Staff could not observe patients in all parts of the wards and outside space. However, the service had fitted convex mirrors and CCTV to monitor communal areas and used enhanced observations to support patients with additional risks.

The ward complied with guidance and there was no mixed sex accommodation. The service only admitted female patients.

Staff had access to alarms and patients had easy access to nurse call systems, however, one staff member told us there was not always enough alarms for everyone to have one. This increased staff anxiety should an incident take place and increased risk of avoidable harm to patients.

The clinic room was clean and fully equipped, although no cleaning records were available in the room as they were stored on an electronic system. There was an air conditioning unit located above the examination couch that was leaking. We saw accessible resuscitation equipment and emergency drugs that staff checked

regularly. However, the resuscitation bag appeared messy and had no tag in place to secure items after checks were complete. Checklists were completed intermittently; we raised this with the provider who confirmed that this was recorded on an in house electronic system. When this information was requested from the provider, we were sent only a checklist confirming the check had been completed. We were not assured that regular itemised checks were being conducted.

There was a comprehensive ligature risk assessment and appropriate furnishings to mitigate risk. However, during our tour of the ward, ligature alarms were inadvertently set off by a staff member on at least 3 occasions. It was noted that on only 1 occasion did a staff member respond to this alarm. We also saw staff not responding to another alarm and staff responding but with no urgency. This increased risk of serious harm to patients on the ward.

Each patient had their own bedroom, which they could personalise. Bedrooms were mainly clean and some had ensuite facilities. Staff did not ensure that bedroom environments were clean and clear, 1 patients’ room was extremely unkempt. Clothes were strewn across the floor and piled up, and high-risk items such as empty bottles and plastic bags were present. This put this patient at avoidable risk of harm and did not provide a therapeutic environment in which to receive safe and effective care.

Staff used a range of rooms and equipment to support treatment and care. The ward had a clinic room, and rooms that could be used for group work, art therapy and activities.

Safe and Effective Staffing

The service establishment staffing was 3 nurses and 3 healthcare assistants and additional staff were used when patients required 1:1 observations. There were 4 vacancies for registered nurses and 1 vacancy for a healthcare assistant. In the past 3 months bank or agency staff were used 432 times to cover sickness, absence or vacancies.
Staff told us that incidents were difficult to manage due to there not being enough staff. One staff member we spoke with told us they were anxious if there was a serious incident as they did not feel there would be enough staff to support them with this. Staff told us that community meetings, getting patients’ hot drinks and incident recording was not always possible due to lack of staffing.
At the time of inspection, the staff sickness rate was 17.2% in October 2025, 16.4% in November 2025 and 16.9% in December 2025.
Managers had calculated the number of nurses and healthcare assistants required. There was a daily staffing call where resources could be moved to cover when the ward was short staffed, however, staff we spoke with did not feel staffing was sufficient to deliver safe care.
Staff had mostly kept up to date with their mandatory and essential training. Overall, compliance was between 60% and 100%. There were 3 pieces of training with a compliance rate of less than 75%. The training programme was comprehensive and met the needs of patients and staff.
Managers gave each new member of staff a full induction to the service before they started work.
 

Infection Prevention and Control

Staff maintained equipment well and kept it clean.
Most ward areas and clinic areas were clean and well maintained, however, 2 toilets and a bathroom were not clean.
Cleaning records were mostly up to date and demonstrated that all areas of the hospital were regularly cleaned, however, some areas could not be cleaned due to inaccessibility, for example, 1 room was covered in patients’ possessions.
Staff followed infection control policy, including handwashing, this was evident in the quarterly handwashing audit that identified 100% compliance. Hand gel was not available at the ward entrance; the dispenser was empty at the time of our inspection. Compliance levels for essential training in infection control was 67%. This fell below the expected compliance of 75%.
 

Medicines Optimisation

Staff followed good practice in medicines management (that is, transport, storage, dispensing, administration, medicines reconciliation, recording, disposal) and did it in line with national guidance.
Staff did not regularly record or review the physical health of patients; 4 of the 7 patients’ records we reviewed did not have side effects monitoring in place for medication they had been prescribed. Three of the 7 had no management plan for physical health, causing increased risk of avoidable harm to the patients.