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 inspection we rated this key question as inadequate. The service was in breach of regulation 12 in relation to safe care and treatment and regulation 13 in relation to safeguarding. The environment was not safe, safeguarding referrals were not completed when necessary, there were sexual safety concerns, learning from incidents was not identified and embedded. Patients were not always risk assessed on admission to the ward. At this inspection we found the service had made improvements and is no longer in breach of these regulations. The rating has changed to good. This meant people were safe and protected from avoidable harm.

Leaders ensured the environment was safe. Ligature risks had been mitigated. A shed with a broken door, containing tools that could be a risk to patients had been removed. A broken fence in the garden had been repaired.

Leaders ensured a safeguarding log was in place. Safeguarding referrals were completed where needed. Leaders ensured sexual safety concerns were addressed. Sexual safety was discussed in community meetings and processes to manage mixed sex accommodation were safe.

Leaders ensured incidents were identified and investigated. Learning from incidents was shared.

Staff ensured all patients had risk assessments in place. All patients were appropriately placed at the service. Leaders had taken action and paused admissions to the service due to safety concerns that were found at our last inspection.

However, we found there were areas of infection prevention and control that were not compliant. This had been identified through the trusts auditing process, and an action plan had been put in place.

There were some outstanding actions from fire safety checks, which had not yet been completed. Leaders told us there was a plan in place for the actions to be completed.

Staff did not always ensure risk management plans were detailed. Leaders were aware of this and told us training would be provided.

This service scored 66 (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.

Leaders ensured incidents were identified and investigated. We reviewed the service’s incident log and found there had been 2 incidents in the last 6 months. There was 1 self-harm incident, where we found appropriate actions were taken. This included an increase in observation level and a request for a transfer due to increase in patient risk.

Leaders had implemented learning from previous sexual safety incidents. We found that sexual safety was regularly discussed in community meetings. Patients were regularly reminded that they could use the sexual safety box to raise sexual safety concerns, which was implemented following our last inspection. There was also evidence that staff had discussed what behaviour would be inappropriate on the ward. There had been no sexual safety incidents since our last inspection.

Leaders identified learning following an incident. After an incident of self-harm, learning included pre-planning difficult discussions with patients.

There had been no incidents requiring duty of candour in the last 6 months. Staff had completed duty of candour training, with compliance being 94%. Duty of candour means health and social care providers must be open and honest about the care they give and use mistakes as opportunities to learn.

Staff knew how to report incidents. This included completing an electronic incident form, discussing the incident in handover meetings and completing a debrief where necessary. Any learning from incidents would be identified and shared with the wider team.

No complaints or compliments had been received in the last 6 months.

We scored the service as 2. The evidence showed some shortfalls. The service did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

At our last inspection the trust were served a warning notice due to unsafe admissions. Following this inspection in June, leaders made the decision to pause admission to the service until safe processes were in place and a CQC re-assessment had been completed.

Managers had ensured that patients who needs could not be met within the service had been transferred to suitable placements. Staff supported these patients through the discharge process by attending assessments, visiting placements and accommodation when preparing them for discharge.

The trust had a discharge standing operating procedure in place, which was approved in July 2025. The policy gave guidance on requirements for patient discharge. This included sharing discharge summaries with the patients GP within 24 hours of discharge. The policy also outlined processes for agreement of discharge, which included a multidisciplinary team (MDT) discussion to ensure patient readiness.

At the last inspection the admission process into the service were not effective and led to patient’s being admitted to the service who individual needs could not be met. We reviewed the trust’s operational policy, which outlined the process for referrals into the service. This included an initial referral, a screening assessment, a full assessment and discussion at multi-disciplinary meetings. Leaders could not be assured that this process was effective as they had paused admissions to the service.

Staff had a better understanding of safe systems, pathways and transitions. Staff we were able to tell us about processes in place to ensure safe admission and discharge from the service. Staff told us they would report any unsafe admissions as an incident.

Managers had oversight of delayed discharges. Delayed discharges were due to lack of suitable accommodation. However, discharge plans were clearly documented in patients care records.

Leaders ensured there was an emergency response procedure, which outlined actions to take in an emergency. This included processes for staff to follow when there was deterioration in a patient.

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 followed processes to protect patients from abuse. Staff were able to explain safeguarding processes and procedures. There was a safeguarding log in place, which documented recent safeguarding incidents. There was 1 safeguarding incident in the last 6 months. Appropriate action to safeguard was taken and a safeguarding referral was completed.

Staff had completed training in safeguarding appropriate for their role. Safeguarding training level 2 compliance was 86%. Safeguarding level 1 and 3 compliance was 100%.

A staff member told us any safeguarding concerns would be discussed with a manager, an incident report would be completed and safeguarding referrals to the local authority would be completed where appropriate.

Patients felt safe on the ward. If they had any concerns about their safety, they would raise this in community meetings or discuss their concerns with staff.

We scored the service as 2. The evidence showed some shortfalls. The service did not always work well with people to understand and manage risks. They did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff worked with patients to ensure that they had care plans in place to manage and mitigate individual risk. We reviewed 3 risk assessments which had been regularly reviewed. However, risk management plans lacked detail of what interventions or mitigation needed to be followed if a patient’s risk increased. We raised this with leaders at the time of the inspection, who were aware of the issue. They reported staff would have additional training in risk management.

However, this was an area of improvement following our last inspection, where not all patients had risk assessments in place.

There were no incidents of restraint, rapid tranquilisation or seclusion at the service.

We scored the service as 3. The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Managers ensured the environment was safe. There was a ligature risk assessment in place, which identified current ligature risks and mitigations. Leaders told us mitigation for ligature risk was for staff to complete observations. We reviewed observation records and found observations were completed appropriately. There were ligature cutters available in the main office and in the clinic room. Staff knew how to access ligature cutters in an emergency. A ligature and CPR emergency simulation drill was completed in February 2026.

There was no closed- circuit television (CCTV) in the main building or in the Coach House. The Coach House was an outbuilding that housed 1 patient at the time of our inspection, however had capacity for 3 patients. There was CCTV covering some areas of the garden, which was mitigation for ligature risks.

Managers ensured mixed sex accommodation was safely managed in line with the trust policy. At this inspection the trust were adhering to same sex accommodation as a female patient was located on the ground floor and male patients were upstairs.

Staff had personal alarms to summon help if needed in an emergency.

An asbestos inspection was completed in April 2026 and the service was rated as low risk.

Since the last inspection managers had mitigated environmental risks. Broken appliances had been removed and the shed with a broken door has been fixed. Another shed had been removed. The garden fence had been repaired. However, some areas of the service needed painting and refurbishment.

A fire risk assessment was completed on 10 June 2026. Overall fire risk rating for the service was medium. This was due to the ceiling in the laundry room needing to be repaired and records of annual emergency light testing not being available. Leaders told us they had been in contact with estates to get the ceiling fixed and were awaiting a completion date. An asbestos inspection was completed in April 2026 and the service was rated as low risk.

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.

There were enough staff to meet patient’s needs. There was a ward manager, deputy ward manager, 4 staff nurses, 6 senior healthcare assistants, 1 housekeeper, an activity co-ordinator and associate practitioner in post. At the time of our inspection there was a vacancy for a deputy ward manager and a housekeeper.

There was an occupational therapy team and an activity co-ordinator at the service. A clinical psychologist attended the service for 1. 5 days per week. There were 2 doctors available to patients for 4 hours per week. Staff told us that there was limited access to a doctor, however they regularly used a local GP.

Staff sickness rates in May 2026 were 7%. No agency staff were being used in the 6 months prior to inspection.

Managers ensured staff were receiving support for their roles. Supervision compliance was 88% and appraisal compliance was 94% at the time of inspection.

Managers had oversight of staff training. Training compliance for basic life support was 94%, training compliance for sexual safety was 100% and for therapeutic engagement and supportive observation was 100%.

We found recruitment processes were safe. Staff had disclosure and barring service (DBS) checks in place.

We scored the service as 2. The evidence showed some shortfalls. The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

Infection prevention and control procedures were not fully embedded. We reviewed infection prevention and control audits from May 2026 and found there were areas of non- compliance. This included gloves and hand sanitiser having expired. Following our inspection, the trust provided an infection prevention and control action plan that was implemented prior to inspection. This included strict stock rotation to ensure that stock was used within the expiry date. Stock was to be checked weekly and was the responsibility of the Nurse in Charge. Staff had completed training in infection prevention and control, with compliance being 94%. This meant leaders had oversight of infection prevention control issues and were addressing the concerns that were identified through auditing processes.

The ward was mostly clean. There was a shared kitchen that had recently been refurbished. Each patient had their own cupboard to store food and fridge temperatures were regularly checked. However, some of the ward needed painting, refurbishment and maintenance. For example, the Coach House needed painting.

There was an infection prevention and control policy in place, which was last reviewed in February 2025. There was a policy in place for the safe disposal of clinical waste, which was issued on 13 May 2026. This included processes for disposal of different types of clinical waste, including sharps.

Patients did not raise any concerns about cleanliness of the ward during our inspection.

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.

Staff ensured that medicines and treatments were safe and met people’s needs. The medicines cupboard and fridge were in good order. All medicines were in date and fridge temperatures were monitored daily. There was an emergency grab bag, which was checked daily. Controlled drugs were in order. There was a controlled drugs log and dispensing of controlled drugs was documented correctly. Medication on consent to treatment forms matched prescription charts.

Leaders ensured appropriate policies were in place. There was a prescribing policy. There was a policy for the safe disposal and secure handling of medicines, which was due for review in May 2026. This outlined the process for staff to take when disposing of medications, including controlled drugs.

However, medicines management training compliance was 63%. We did not see any medication errors had taken place.