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 as requires improvement. We found a breach of regulation 17 in relation to good governance. Leaders did not have effective or robust governance processes. Managers did not have oversight of staff supervision. There were not adequate systems in place to monitor the assessment of risk or oversight of incidents. Concerns relating to safety of the environment were not effectively managed.

At this assessment the rating changed to good and the service was no longer in breach of regulation 17.

Leaders had robust governance processes in place. Managers had oversight of staff supervision and compliance had improved since our last inspection. Leaders had oversight of incidents. Managers had oversight of the management of risk.

This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

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.

Managers were embedding a culture of transparency. Most staff told us they would raise concerns with managers and action would be taken. This was an area of improvement since our last inspection, where staff did not always feel they could raise concerns.

Leaders told us the review and re-design of 439 Ipswich Road had been paused following the last CQC inspection. Discussions about strategy for the service had been put on hold but would be recommenced following the findings of the inspection.

Essex Partnership University NHS Foundation Trust had a strategic plan in place. This included a vision “to be the leading health and wellbeing service.” Strategic development plans included review of policy, engagement with service users and a review of service demand.

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.

The trust had programmes available to support leaders in their role. For example, there was a Management Development Programme for Managers to support with developing skills in leadership. Leaders told us they felt supported and senior leaders were visible.

Leaders had the knowledge to perform their roles. Leaders were able to explain why they had decided to pause admissions to 439 Ipswich Road, following the last CQC inspection. Leaders were embedding processes to ensure patients’ safety on the ward.

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.

Leaders were embedding a speaking up culture. Most staff could raise concerns with leaders and felt they would be listened to. There was a freedom to speak up policy in place, which was last reviewed in February 2026. This outlined duties and responsibilities of staff. There was also a clear process to follow when raising a concern. Freedom to speak up training compliance was 100%.

The trust provided a “you said, we did” response to staff surveys, which showed action taken to address staff concerns that were identified across the trust.

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 a flexible working policy, which was last reviewed in March 2024. This outlined the procedures for staff to follow when applying for flexible working. Staff told us leaders were flexible and they would be able to work flexibly if requested.

Most staff that we spoke with told us that managers were supportive and approachable. However, 1 staff member felt they were not always treated fairly.

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 ensured effective business meetings were taking place. We reviewed business meeting minutes and found there was a clear agenda. Leaders ensured risk issues were discussed and actions were put in place. For example, there was evidence of staff being reminded of processes to follow where there were safeguarding concerns. Actions were also identified. For example, one action was for the team to review the sexual safety flow chart.

Leaders ensured governance meetings were held monthly. We found quality and safety meeting minutes included discussions on safety, performance and audits. Actions were identified where needed. For example, where there had been an increase in medication errors across other Essex Partnership University NHS Foundation Trust services, actions included introducing photo identification and to reinforce the use of 2 patient identifiers.

Leaders ensured there was a risk register in place. The service risk register included concerns found at our previous inspection, relating to safeguarding, managerial oversight and governance. The risk register detailed actions that had been taken, including training needs that had been identified.

Leaders had oversight of governance processes. Clinical audits were completed and monthly audit reports were produced. Leaders told us findings were discussed at quality and safety groups. This meant that leaders monitored compliance and were able to identify any areas of improvement.

Leaders ensured staff had access to regular supervision. We found supervision compliance had improved since our last inspection.

There was a business continuity plan in place, which was last reviewed in September 2025. This gave details of appropriate contacts and a plan for events that could impact the running of the service.

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.

Leaders ensured the service worked collaboratively with other organisations. Patients had access to the Big Garden Project, which was provided by a Community Interest Company (CIC). The service also worked in partnership with Pet Therapy services, who attended the ward weekly.

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 demonstrated continuous learning and improvements in quality of care through “5 key messages” that were shared monthly. This included essential information that needed to be shared across the trust. For example, there was information for staff about consistent use of shared email inboxes, task allocation and safe systems to support care and treatment.

The trust told us they worked collaboratively with the National Institute for Health and Care Research (NIHR), as well as other networks to support evidence-based innovation, research participation and service development.

The trust had a Quality and Safety Champions scheme, designed to create a culture of quality and safety across all Essex Partnership University NHS Foundation Trust services.

The trust told us they had a Quality Improvement Framework, which supported teams to undertake improvement projects. Leaders told us that quality improvement was supported through training, coaching and guidance from the quality improvement team. Previous improvement work has included reducing restrictive practice.

Leaders told us staff had access to research training, fellowship opportunities and career development pathways.