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.

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.

Shared direction and culture

Staff were mostly aware of the trust’s values of ‘we care, we learn and we empower’ and mostly demonstrated these values in their day-to-day work.
The provider’s senior leadership team had successfully communicated the provider’s vision and values to the frontline staff in this service.
Staff felt mostly supported by senior leaders who were visible and approachable. However, they did not feel the minimum establishment numbers for the ward enabled them to provide safe and effective care raising the risk of avoidable harm to staff and patients.
 

Capable, compassionate and inclusive leaders

At the time of the inspection there had been a gap in permanent leadership on the ward. Staff told us not having a ward manager was challenging and had a detrimental effect on them and their wellbeing. A newly appointed ward manager was present on the day of our inspection but had not had time to embed. A newly appointed matron had also started on the ward.
Staff told us leaders were visible in the service and approachable for patients and staff. However, due to low staffing they were taking on additional tasks such as enhanced observations. This highlighted significant gaps in the resources needed to provide safe and effective care, as well as a lack of therapeutic engagement during enhanced observations.
 

Freedom to speak up

Patients and carers had opportunities to give feedback on the service they received, and a family member told us they received a response when they raised concerns. However, patients told us community meetings did not always take place as planned and their repeated concerns were not always addressed, for example the hot tap to make drinks was not functioning effectively.
The trust had a freedom to speak up guardian to support staff. However, some staff told us they had raised concerns regarding staffing and safety on the ward but had not seen changes to establishment numbers.
 

Workforce equality, diversity and inclusion

There were equality and diversity champions within the service.
There were Staff Equality Networks within the Trust, including Ethnic Minority and Race Equality Network, Disability and Mental Health, Faith and Spirituality and Lesbian, Gay, Bi, Trans and any other sexuality or gender identity group (LGBTQ+).
Staff were able to apply to work flexibly, for example, flexible working agreements to account for personal circumstances such as caring responsibilities and health issues.
Staff did not raise any concerns about discrimination; they told us that an example of racial abuse from a patient was handled appropriately within a community meeting.
 

Governance, management and sustainability

Our findings from the other key questions demonstrated that governance processes were not always effective at team level and that risk was not always managed well. An example of this could be seen in the observation allocation policy not being followed.
There was a clear framework of what must be discussed at a ward, team or directorate level in team meetings to ensure that essential information, such as learning from incidents and complaints, was shared and discussed. However, staff did not always complete this in detail, for example, team training compliance was raised in manager’s feedback, yet this was not referred to in actions/outcomes. This made it more difficult to maintain effective governance of outstanding actions ahead of subsequent team meetings.
We reviewed audits required for the trust, including Ardleigh ward. During October 2025, staff did not always comply with data submissions for the audits. For example, fire safety and health and safety audits were due to be submitted once a month. However, staff on Ardleigh ward had not made a submission for the last 6 months.
The risk register did not include all risks for the ward that were present. We were therefore not assured that all risks were recorded and monitored appropriately, causing increased risk of avoidable harm to patients.
The service had contingency plans for emergencies – for example, an outbreak of fire.
Staff had access to the equipment and information technology needed to do their work. The ward used the Electronic Prescribing and Medicines Administration (ePMA) system, the EPUT care portal where information sharing takes place and Oxivision, which was a contactless monitoring system in the bedrooms. This monitors heart rate, breathing rate, location and movement, without the need for physical contact.
 

Partnerships and communities

Patients and staff could meet with members of the ward’s senior leadership team to give and receive feedback.
 

Learning, improvement and innovation

Innovations were taking place in the service to make improvements, including the introduction of Registered General Nursing staff to the ward. This assists in a holistic overview when creating care plans for patients. The ward had recently recruited a permanent manager and matron to the ward to better support staff and patients.