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

At our last inspection we rated this key question as inadequate. Following this inspection, the rating has improved to requires improvement. Since the last inspection, the trust had made improvements to the previous breaches we had identified where 23 out of 25 breaches were now met. During this inspection, we found 1 breach of the legal regulation safe care and treatment for prescribing, administering and recording of medicines, which was also identified at the last inspection. Although there were processes in place to ensure patients were receiving their medicines safely and as prescribed, these were not always being followed. Medicine allergies were not always recorded on prescription charts. There were sometimes gaps in administration records where it was not clear if a prescribed medicine had been given or not. Care plans we reviewed for specific health conditions sometimes lacked detail or had inconsistencies in the information included between different documents. Staff did not always follow NICE guidance when using rapid tranquilisation. Instances we reviewed of the use of rapid tranquilisation (RT - use of medicines intramuscularly to reduce extreme agitation/distress) showed that required post dose physical health monitoring was not being completed in line with the Trust policy or national guidance. Staff did not review when required medicines to ensure its continued use was appropriate and having the desired effect. Some records indicated that patients were given medicines over the maximum recommended doses within a 24 hour period.

However, the trust had effective processes in place for learning from incidents and complaints which were shared across wards. Multi-Disciplinary Team meeting minutes demonstrated patients’ views were sought and the trust engaged with partners to support patients with their admissions and discharge. The trust had a clear process to record and investigate safeguarding concerns. The trust took a proportionate approach to imposing restrictions on patients and restrictive practice was reducing. There were appropriate staffing levels and skill mix to meet patients’ needs. Although there were some issues with the environment and repairs, the trust had a refurbishment plan in place and were fixing the faults. The trust had an infection, prevention and control (IPC) policy, which was reviewed regularly, wards were clean and hygienic with suitable facilities to enable effective Infection Prevention Control.

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.

Patients on most wards felt able to raise concerns and knew who to raise these with. We observed a community meeting at Cherrydown ward Basildon mental health unit where patients were encouraged to give open and honest feedback. All patients except those at Basildon Mental Health Unit and Rochford Hospital said they had a de-brief following an incident. We saw examples of meeting minutes where patients had raised issues on all wards. However, community meeting minutes did not always demonstrate follow up of actions and outcomes.

Staff we spoke with knew what incidents to report and how to report them. Staff told us they had received feedback following safety incidents and where actions had been taken. Staff and managers told us they had debriefs following incidents. Managers explained the processes for dealing with accidents, incidents and complaints and gave examples of these. For example, following the first week of our inspection, a dashboard had been promptly created to improve the monitoring of rapid tranquilisation. Learning from this was shared across sites. Staff and managers were aware of a tailgating incident on Peter Bruff ward where action to install an airlock was taken.

There were systems in place for the recording of incidents and immediate actions taken to address these. The trust had effective processes in place for learning from incidents and complaints which were shared across wards and sites. Staff feedback and clinical governance meetings demonstrated that complaints and incident learning were regularly shared and that processes had been embedded. For example, staff and managers described being involved in learning and participating in safety huddles, de-briefs, reflective practice meetings and team meetings. Staff also spoke about receiving regular incident information in the form of monthly 5 key messages and regular incident briefings. Managers spoke consistently about attending meetings to review learning from incidents. The trust had current improvement plans reflecting their current issues. We reviewed these and saw these were logged, reviewed and acted upon to ensure improvements were made. Managers spoke about learning from deaths and inquests across all wards. The trust were still working on improving their oversight of deaths and embedding their processes to combine learning and outcomes from inquests. However, we did see that the trust reviewed themes of deaths, for learning, in the monthly inpatient quality and safety committee meeting. In November 2024, themes surrounding learning from deaths were associated with neurodivergence and physical health. As a result, the trust were reviewing their environments to ensure sensory needs were supported for neurodivergent patients and were working with learning disability and autism commissioners to support the trusts neurodiversity strategy.

To improve physical health monitoring the trust ensured staff were still able to obtain physical health checks of patients using a non-contact approach where staff measured vital signs such as pulse, breathing rate and movements without having to touch patients who declined physical health checks. The trust were also ensuring staff recorded physical health checks for patients that were taken using the non-contact approach so that all physical health checks were being recorded.

Most patients told us they felt safe on the wards. Patients had mixed views about their experiences of admissions, transitions and discharges on the wards. Most patients said they were given information on admission and shown around the ward. However, many patients said they were frustrated with the delays to being discharged, although 2 patients had a positive experience with this. Some patients felt they needed more employment and housing support when transitioning back into the community.

Staff orientated patients to the ward and said they provided patients with information about their treatment, rights, advocacy and welcome information.

Managers were aware of challenges they faced with the environment at their mental health suite in Colchester where patients were first seen and assessed leading to admission to hospital. These included access to food and showers and the environment, which were not comfortable for patients, as the room was small and did not have a window. Managers were taking action to improve their patients experience of this service.

Managers sometimes experienced challenges in managing patient flow between admissions and discharges. They spoke about the impact of delayed discharges and other system delays that led to patient bed capacity issues. This meant there could sometimes be no beds available to admit patients from urgent care. Senior leaders were aware of this and continued to ensure discharge co-ordinators, liaison staff and urgent care teams were addressing challenges with patient risk, flow and discharges. The trust were working with general hospital colleagues to improve how they worked together to support mental health patients and improve patient flow at general hospitals.

Managers spoke about some pathways not being clearly defined, specifically pathways for patients with emotional and unstable personality disorder and learning disabilities. Managers said this impacted patient flow across the wards.

Staff and managers spoke about the high acuity on wards and that managing risk could be a challenge but that keeping patients safe was their priority.

As a result of recent incidents, managers implemented a new observation policy to improve staff observations of patients. This focused on engagement with patients, staff well-being, tailoring observations to meet patients’ needs and observations being regularly reviewed.

Staff and managers spoke about the challenges they sometimes faced when working with the police who referred to the right care, right person model where this could be a challenge in managing the risk for patients on leave or under urgent care.

Managers had links with social services and external organisations which enabled them to support patients with access to the community, transitions and discharges.

We sought feedback from members of integrated care boards, local authorities and other stakeholders across Essex, to obtain their view of the trusts systems, pathways, patient flow, safety and quality. Integrated Care Board members attended several of the trust’s quality and safety meetings where they received information and assurance, challenged and discussed actions and mitigation. They said they worked well with the trust and staff were open and approachable.

Integrated care boards worked with the trust to focus on complex patients and those with long stays and who were homeless. They participated in various forums with the trust, where patient flow, discharges, safety and quality were discussed.

The Integrated Care Board participated in the trusts patient safety oversight group which was part of the Patient Safety Incident Response Framework (PSIRF) providing a strategic direction and ensuring the trust aligned with national and local safety priorities.

Managers ensured safe systems by having oversight of the wards through regular meetings with ward managers and matrons. Senior managers reviewed incident data, action plans, care pathways, and held regular meetings with managers and teams. Following the previous inspection, managers introduced a clinical site officer to ensure the oversight, safety and function of each site during out of hours and at the weekend. The officer ensured tasks and roles were allocated sufficiently, the services were safe, and staff were supported with breaks and well-being. They also held regular safety huddles with staff to ensure this was an embedded practice at night.

The trust had policies on referrals, admissions and discharge outlining the process in place for these. Multi-Disciplinary Team meeting minutes demonstrated patients’ views were sought and the trust engaged with partners to support patients with their admissions and discharge. The trust recorded estimated dates of discharge in care review meetings. However, not all wards recorded barriers to discharge, and the actions taken to address these. Evidence of involvement with care co-ordinators and other stakeholders supporting discharge were evident in minutes.

The trust had discharge co-ordinators working with wards and partners to discharge patients. The trust were revising their pathway model where they were reviewing the purpose of an admission and reasons for delays to discharges with system partners and discharge co-ordinators. The aim of this was to focus on any obstacles to discharge to improve the patient flow and discharge process. Senior managers said they worked with local integrated care boards and local authorities to review the timeliness of patient admissions and discharges with the focus to improve system flow and patient experience. Managers also spoke about implementing the time to care model that had enabled teams to improve the standards of care that were consistent across wards.

We spoke with patients of which most told us they felt safe on the wards. Community meeting minutes took place regularly on the wards and safety and well-being were discussed. Patients said they were able to raise concerns, and that staff took action to address these. However, patients did not always receive the outcome from investigations.

Staff knew how to make a safeguarding referral and escalate concerns. Staff could describe how they had protected patients from harassment and discrimination, including those with protected characteristics under the equality act. For example, staff shared an incident where they had identified and reported financial abuse. Staff knew how to recognise adults and children at risk of or suffering harm and were aware of the processes to follow to report and record this. They worked with internal departments and external agencies to protect patients.

During the inspection, we generally observed patients being supported by staff who understood how to protect patients from harm. However, we observed 2 poor interactions from staff towards patients on Ardleigh ward where staff were not observed to be engaging or responsive to patients. We shared our observations with the trust. The trust were aware of some challenges on Ardleigh ward and had moved senior staff to work on the ward to focus on embedding their acute therapeutic inpatient model, ‘Culture of Care.’ This included modelling behaviour, providing support with safeguarding and working with their advocacy provider to improve the experience of care for patients. We also conducted a night visit where we gained further assurance on the engagement and interactions between staff and patients.

We observed staff quickly and appropriately defuse a potential incident at another location. We saw posters displayed on wards giving information about safety, advocacy, patients’ rights and how to make a complaint.

The trust had a clear process to record and investigate safeguarding concerns. We reviewed the safeguarding log, which was up to date, included details about safeguarding incidents and if it was being investigated internally or by the local authority. The log demonstrated reporting, oversight, review and safeguarding outcomes. The trust had a safeguarding policy and clear processes in place for staff to follow. Managers spoke about a sexual safety charter they had embedded on the wards. Staff participated in mandatory sexual safety training and managers developed flow charts for staff to follow on how to manage sexual safety incidents and what actions to take.

We spoke with patients who told us that although they were usually given a copy of their care plans and risk assessments, they were not always involved in these. We spoke with 6 patients at Colchester Mental Health hospital, 3 patients on Ardleigh ward fed back that incidents of restraint they were involved in were not always managed well. However, patients on other wards reported better experiences of being restrained. Some patients felt staff managed incidents well and supported them in situations of distress. Some patients felt that de-briefs after an incident had enabled them to be more involved in how their care was managed in the future.

Staff we spoke with showed a good understanding of the management of risk and reducing restrictive interventions. Staff spoke about using restraint and seclusion as a last resort and gave several examples of interventions they would use to manage and de-escalate situations. Staff said they knew patients, and this helped them to support patients and prevent potential incidents from escalating. Staff spoke about understanding patients’ formulations of risk and positive behaviour support plans so that they knew how best they could support them. Staff regularly updated care plans and risk assessments following incidents. We saw examples where risk assessments had been updated following incidents of restraint that included patient views. Managers told us they reviewed incident information to monitor trends at locations and sent incident briefings to staff so that they were aware of the themes and trends for their service.

The trust had a reducing restrictive interventions policy which included guidance and procedures for managing and reducing restrictive practice. This was aligned to the trusts quality of care strategy led by directors and included input from expert by experience and safety partners. The trust joined the reducing restricting collaborative partnership agreement where other trusts were responsible for assuring the quality of each other’s reducing restrictive practice work and undertook peer review visits.

The trust held monthly restrictive practice group meetings. We viewed minutes between September 2024 and November 2024 where all areas of restrictive practice were presented. Senior leaders told us that a thematic review of seclusion and Long Term Segregation was completed which showed a reduction in restraints, use of seclusion and long term segregation and the number of non-fixed ligatures on adult wards from September 2024 compared to last year. The trust felt the focus on Safewards (a program that aims to reduce the restraint and seclusion of patients on psychiatric wards) had helped to reduce these. At the Basildon mental health unit, a number of staff had completed the Post Graduate certificate in reducing restrictive practice.

Patients were generally satisfied with the environment and equipment on the wards, although some patients raised concerns about the facilities on Ardleigh ward. Two patients said the kitchen could be messy, the toilets were sometimes blocked, and soap and tissue roll were not always replenished. Overall, patients said they could access the garden and could access drinks and snacks. Patients had access to lockers to store personal belongings and valuable items. Following risk assessments, patients could use ward or mobile phones on the wards. Most patients said the environments were comfortable but 1 patient at the Linden Centre and 1 patient at Rochford hospital said the wards were noisy and echoey.

Staff we spoke with knew about any potential ligature anchor points and mitigated the risks to keep patients safe. Staff had access to personal alarms along with radios to communicate across wards and used body worn cameras on the ward with the aim to reduce risks to patient and staff.Staff assessed environmental risks to patients and took action to reduce risks where possible. Staff were aware of the security on the ward and what the role of the person allocated to security involved. Staff described the processes for searches and how they conducted observations on the wards. Staff were aware of blind spots within the service and knew how to mitigate against these. The trust had fitted mirrors and closed-circuit television to monitor communal areas and staff used enhanced observations to support patients with additional risks.

We observed a potential ligature risk in patient bedroom corridors and in rooms on Chelmer ward at the Derwent Centre. However, on review of the ligature risk assessments these were included, rated and mitigated.

We also observed that the ward storeroom was cluttered, and the emergency evacuation chair was blocked in on Chelmer ward, which would be difficult to access in an emergency which we raised with managers. Parts of the environment on Cedar ward at Rochford hospital had delays to some repairs on the ward. Two accessible bathrooms and two extra care bedrooms required repairing and although reported had lengthy delays to being fixed. These rooms were not in use at the time of the inspection. Patients used en-suite facilities to shower in their bedrooms. Cedar ward had no seclusion room which could be challenging when managing a patient at risk.

Wards at the Linden centre had a laminated ‘hot spot’ document that was not up to date and was complex which made it hard for new staff to retain. We observed that the ligature hot spot document, rated as red and amber, did not indicate if actions were completed.

We reviewed maintenance logs for Cedar ward where the heating was a reoccurring issue that required repairing. Several bedrooms were reported to have heating that was not working and although this was repaired, they were reported as not working repeatedly. However, overall, across the trust repairs were fixed in a timely manner.

Although the trust completed regular and up to date environmental, health and safety risk assessments, managers had not ensured the repair of some aspects of the ward environments at the Linden Centre, Rochford hospital and the Derwent centre. However, the trust generally made repairs in a timely manner. The trust had a process in place in line with its therapeutic observations and engagement policy to carry out patient observation.

The service was clean, generally comfortable, decorated and furnished well. The wards complied with guidance and there was no mixed sex accommodation. We observed staff having easy access to, and using, alarms and patients had easy access to nurse call systems in their bedrooms. In addition to observations, the trust used the monitoring system called Oxevision, where infrared cameras were used to remotely track and monitor patients’ vital signs 24 hours a day whilst they were in their bedrooms. Staff were able to monitor patients’ well-being, detect potential risks and were alerted if patients presented with a risk to their safety. The trust sought consent from patients prior to using Oxevision and we observed consent forms, posters and information informing patients of its use. Staff explained the purpose of Oxevision to patients and requested consent from patients on admission.

Staff on Hadleigh ward at Basildon Mental Health Unit, had not completed daily trolley checks on 3 occasions during October 2024 and the suction machine was not recorded as being cleaned in the cleaning records. The suction machine was kept at the back of a cupboard and was not left on charge so that staff could use this in case of a choking emergency.

We spoke with patients across 9 wards who all told us that there were enough staff available, they could see a doctor when they needed to, they could access activities and therapy and access community leave. Some patients felt 2 wards were busy and that staff were not always visibly present in the communal areas.

Managers reported that staffing had improved across the wards with the introduction of the time to care approach. Staff we spoke with knew their patients and their needs well. Managers were able to adjust staffing levels to meet the needs of the patients on the ward. Managers told us they tried to ensure regular bank staff were booked when required. Patients had access to a multidisciplinary team including for example, medical staff, nursing staff, health care assistants, activity co-ordinators, occupational therapists and psychology. Staff also told us they benefited from having access to specialist nursing support. This included physical health nurses, tissue viability nurses and Parkinson’s nurses where they were needed.

The trust used the Mental Health Optimal Staffing Tool (MHOST), to review and assess their staffing numbers. Following CQC’s on-site visit, CQC received concerns about the changes to staffing levels and the potential impact on staffing levels and safety on some wards. Managers responded to these concerns and explained they had recently reviewed and changed their staffing levels to increase the number of registered nurses on shift. The aim was to reduce the number of temporary staff being used, improve the quality of care and to utilise a more multi-disciplinary team approach that included new peer and family ambassador roles.

As part of the inspection, we observed 9 out of 9 wards. Our observations showed that on the days we visited the wards there were enough staff to complete therapeutic observations and to actively engage with patients. However, some staff interactions with patients on Ardleigh ward were not supportive or engaging when patients had made requests or were seeking support. For example, we observed a staff member calling a patient rude. We conducted a further night visit and gained assurance on staff engagement and interactions with patients.

The trust held twice daily calls on staffing with operational directors and senior nurse involvement to look at all rostering with escalations in place where patient and staff safety concerns were identified. They also held weekly meetings to look at safer staffing alongside temporary staffing with patient safety and staff wellbeing at the centre of decision making.

The wards had low vacancy rates. At the time of inspection, the vacancy rate for whole time equivalent qualified nurses ranged between 4.7 for Finchingfield ward and 0.2 on Ardleigh ward with the remaining wards ranging between these figures. Healthcare assistants’ vacancy rates were low with the only vacancy being on Finchingfield ward at 0.7.

The service had varied sickness rates in October 2024, ranging between the highest on Finchingfield ward at 14%, 7% on Chelmer ward and 8% on Galleywood ward and Christopher unit. The lowest sickness rate was 1% on Cherrydown ward. The wards had an increasing turnover rate in October 2024, which varied between wards. The highest turnover rate was 21% on Finchingfield ward, 19% on Chelmer ward, 18% on Galleywood ward and the lowest was 1% on Cherrydown ward which had reduced since the previous month. The remaining wards had a turnover rate varying between 5% and 10%.

Managers used bank staff and agency staff to fill shifts to cover sickness, absence and vacancies. Managers tried to book regular bank and agency staff when required. The trust was proactive in recruitment including the use of overseas recruitment and internal staff development. The trust had a comprehensive mandatory training programme in place with training to meet the needs of staff and patients. Training figures showed staff were compliant with mandatory training including Mental Health Act Training and Intermediate Life Support. On some wards managers did not ensure staff received regular supervision and appraisals.

On 8 out of the 9 wards we visited patients said the wards were clean, tidy and well maintained and the wards had good domestic teams. On Ardleigh ward patients said there were times when there was no soap or toilet roll in the bathrooms and patients had to ask staff. We observed this being discussed in the community meeting.

Staff said the environment was kept clean and there were appropriate arrangements for maintaining good standards of cleanliness and hygiene. Leaders carried out quarterly infection, prevention and control audits to monitor cleanliness and hygiene and ensure infection, prevention and control processes were effective.

Wards were clean and hygienic, the wards had suitable facilities to enable effective infection prevention control. There was suitable guidance in the buildings to prompt patients on safe infection prevention control, for example, we saw posters displayed on handwashing. On 8 out of 9 wards food was stored hygienically. On 1 ward we observed items in the dairy and patient fridge that were not labelled or dated, and the patient refreshment area was not clean. However, staff addressed these issues once we had let them know. On Finchingfield ward at the Linden Centre, cleaning record checks were not recorded 6 times in October 2024 and 6 times in November 2024.

The trust had a detailed Infection Prevention Control policy, which was reviewed regularly, a policy at a glance with staff responsibilities was also available. IPC audits and action plans were viewed for 5 wards, out of 9 with compliance over 80% on all action plans were sent out after audits and there was evidence of actions being taken and signed off. Quarterly Infection Prevention Control audits were also carried out with 8 out of 9 wards 80% and above.

Patients were not always monitored after receiving rapid tranquilisation (RT - use of medicines intramuscularly to reduce extreme agitation/distress). Some records indicated that patients were given medicines over the maximum recommended doses within a 24 hour period or without the recommended interval between doses. Patients’ care plans for specific health conditions lacked detail or had inconsistencies in the information included between different documents. Although patients were supported to receive their medicines in a timely and effective way, they were not involved in decisions about how they would like to receive their medicines to ensure this met their individual preferences, where possible. Some medicines which are recommended to be given prior to other medicines or before food and drink to ensure they would be as effective for the person as possible were not being given in line with the manufacturer’s recommendation or at the correct times. Patient discharges and leave were sometimes delayed due to limitations and complications with the new electronic prescribing system. This caused a delay in them getting their prescribed medicines ready in time for the leave. However, the trust were aware of these issues and were taking action to address these.

Staff we spoke to about rapid tranquilisation were not clear on what the trusts monitoring and debrief policy was or how they were expected to follow it. Pharmacy staff we spoke with were aware of issues regarding rapid tranquilisation and were providing further training to staff on this. Staff we spoke to were unaware of the administration guidance and clinical pharmacy checks had failed to identify the need to give medicines earlier than was written on the prescriptions. This meant that some medicines may not be working as effectively as they should be for those patients. Staff told us they received a mix of online and face to face training to support them with medicines management. There had also been seminars provided by the pharmacy department into the appropriate way to manage controlled drugs. Staff attended handover meetings where patients’ treatment with medicines would be reviewed. Any errors, omissions or concerns with medicines were escalated at this meeting. Staff told us pharmacists were available on the ward every day and they received deliveries from the pharmacy dispensary 3 times a day. Outside of regular hours staff had access to an on-call service and emergency medicines cupboards to ensure timely access to treatments if needed. One member of staff told us that pharmacy’s presence and support on the unit was ‘invaluable.’

On most wards we visited staff recorded cleaning record checks of the clinic rooms however on Hadleigh ward staff failed to record cleaning record checks of the clinic room on 3 occasions during October 2024 and we could not locate any record for September 2024.

We also identified gaps in room temperature recording and gaps for the end of month review by managers on Finchingfield ward and Galleywood ward.

Controlled drugs were stored in line with requirements and routine checks of levels were completed by staff.

Managers had not ensured staff regularly recorded cleaning checks, room temperatures and equipment checks on Hadleigh ward and Finchingfield ward. There were processes in place to ensure patients should receive their medicines safely and as prescribed, however these were not always being followed. There were sometimes delays in patients obtaining prescribed medicines because staff had not escalated concerns of medicines not being in stock, this included antibiotics where a delay in initiating the treatment could lead to a deterioration in the person’s condition. The Trust had recently implemented a new electronic prescribing and medicines administration (ePMA) system. Staff were still in the process of learning the system and understanding the data it holds and how it could be used to help inform safer and more effective care. Medicine allergies were not always recorded on prescription charts which increased the risk staff may give a medicine which a person was allergic to. There were also sometimes gaps in administration records where it was not clear if a prescribed medicine had been given or not.

We could not find records of follow up investigations which ensured the medicine was given as prescribed. Care plans we reviewed for specific health conditions sometimes lacked detail or had inconsistencies in the information included between different documents. For example, an epilepsy care plan lacked any detail about the type of seizures that occurred, potential triggers and treatment recommended, another for diabetes management had different target ranges for blood glucose and when to give rapid acting insulin. Where patients were prescribed medicines which can impact on their physical health and require routine monitoring this was not being recorded. Care plans and risk assessments often failed to identify these medicines and what the expectation was for staff to keep patients treated with specific medicines safe. Some prescriptions for ‘when required’ (PRN) medicines lacked important details such as the maximum daily dose of the indication that the medicine is prescribed for.

Instances we reviewed of the use of rapid tranquilisation (RT - use of medicines intramuscularly to reduce extreme agitation/distress) showed that required post dose physical health monitoring was not being completed in line with the Trust policy or national guidance. However, following this feedback, the trust had developed a dashboard to improve the monitoring of rapid tranquilisation.

There was a high use of ‘when required’ (PRN) oral medicines for the management of anxiety/agitation and insomnia on both wards. Where these medicines were being used regularly and at the highest available dose, we did not see mention of this use being reviewed in multi-disciplinary team meetings to ensure its continued use was appropriate and having the desired effect. Some records indicated that patients were given medicines over the maximum recommended doses within a 24 hour period or without the recommended interval between doses. This could lead to over sedation and increased risk of side effects from medicines. We were not assured that PRN medicines were always being used safely. There were a number of errors that had been identified by the trust and recorded for both wards visited at Colchester. However, some of these errors are the same as we identified on the inspection, which would suggest that learning and changes to practice were not being effectively implemented when things do go wrong.