The Care Quality Commission
  • Mental Health
  • Independent mental health service

Queensway Hospital Also known as Oak Tree Forest Limited

Overall: Good read more about inspection ratings

136 Moorgate Road, Rotherham, South Yorkshire, S60 3AZ (020) 3981 7252

Provided and run by:
Oak Tree Forest Limited

All Inspections

During an assessment of Acute wards for adults of working age and psychiatric intensive care units

Date of inspection: Tuesday 16 and Wednesday 17 June 2026.

Oak Tree Forest Limited provides inpatient complex care for adults at Queensway Hospital. For the purposes of service classification, the service was assessed within the acute wards for adults of working age service type. In addition, we expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.

We rated the service as Good.

We found that patients were supported to have choice and control, were involved in planning their care and staff were fully invested in clients’ wellbeing. The hospital identified and supported the wider health needs of patients, wellbeing and communication needs. We found the hospital focussed on reducing restrictive practice using a collaborative multidisciplinary approach. The hospital worked in collaboration with external partners, and the organisation encouraged improvement initiatives. However, we found that governance process did not always operate effectively and audits did not always identify issues and provide assurance. 

Mental Health Act and Mental Capacity Act Compliance Summary

97% of staff completed mandatory training in the Mental Capacity Act (MCA) and the Deprivation of Liberty Safeguarding (DoLS), Mental Health Act, the Code of Practice and the guiding principles.

The staff we spoke with had a good understanding of mental capacity and were confident about how to assess it. Staff told us they took all practical steps to enable patients to make their own decisions and provided good examples of how to raise safeguarding concerns.

Patients had easy access to information about independent mental health advocacy. 

We reviewed 5 care records and found evidence that most people's needs were met in line with current guidance and by undertaking capacity assessments and best interest decisions when appropriate. All detained patients were made aware of their rights and patient restrictions were regularly reviewed to maximise their independence.

Multi-disciplinary team discussions involved the patient and patient's family in decision making and planning care and treatment. The hospital demonstrated good governance and had compliance audits in place to ensure staff provided evidence-based care and treatment. 

During an assessment of the hospital overall

We assessed Queensway Hospital from Tuesday 16 to Wednesday 17 June 2026.

The service was registered by CQC on 10 May 2011 as a service provided by Oak Tree Forest Limited to deliver the regulated activities: Treatment for Disease, Disorder and Injury and Assessment or medical treatment for persons detained under the Mental Health Act 1983. 

This was the first inspection of the service since it was renamed and changed its service provision from a specialist eating disorder service to acute wards for adults of working age. At the time of the inspection, the hospital had a registered manager and a controlled drugs accountable officer.

The previous assessment service group of specialist eating disorder service was rated Good overall with Good in all key questions other than well-led which was rated as Requires Improvement, published on 14 February 2025.

Oak Tree Forest Limited provides inpatient complex care for adults at Queensway Hospital. For the purposes of service classification, the service was assessed within the acute wards for adults of working age service type.

At the time of the inspection, the service provided treatment and care for adults detained under the Mental Health Act or as an informal patient. The service offered bespoke therapeutic packages meaning the package of care was tailored to the specific needs of the individual to support their journey towards recovery and independence. The service had 12 beds. At the time of our inspection there were 9 patients admitted to the ward. 

At this assessment we assessed 1 assessment service group: acute wards for adults of working age.

We rated the service as Good. We found 1 breach of regulation in relation to good governance.

During an assessment of Specialist eating disorder services

Date of assessment Monday 18 to Thursday 21 November 2024

Ellern Mede Moorgate is a specialist independent eating disorder service based in Rotherham. It is part of the provider Oak Tree Forest Limited. At the time of inspection, the service provided treatment and care for individuals detained under the Mental Health Act or informal. At the time of our assessment, the service had 6 beds available on Aztec ward and 4 young people currently using the service.

We rated the service as good. The service had made improvements to ensure that staff were skilled to undertake physical interventions, there were regular reviews and care plans now guided safe practice. The provider now had enough staff to ensure people’s safety and access to psychological therapies to meet their needs. People were now treated with kindness, respect and compassion and supported to be involved in planning their care. The provider had reduced restrictions on young people and carried out pre and post leave risk assessments. However, governance processes did not always operate effectively at team level. We found some discrepancies and inconsistencies between documented procedures and processes and staff practice and a lack of oversight or monitoring of this. During this assessment we identified a breach of regulation 17 for good governance.

This service has been in Special Measures since 28 April 2024. The provider demonstrated improvements that have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures. We have asked the provider for an action plan in response to the concerns found at this assessment.

During an assessment of the hospital overall

Date of assessment: Monday 18 to Thursday 21 November 2024. Ellern Mede Moorgate is a specialist independent eating disorder service based in Rotherham. This assessment looked at specialist eating disorder services which we rated as good. In our assessment we found the service demonstrated improvements that have been made. However, governance processes did not always operate effectively.

23 and 24 January 2024

During a routine inspection

Our rating of this location went down. We rated it as inadequate because:

  • The service did not provide safe care. The wards did not have enough nurses and reliance on agency workers was high. Staff did not always assess or manage risk well and incidents causing harm to people using the service occurred during our inspection. Staff did not minimise the use of restrictive practices and people using the service told us about the negative impact this had on them.
  • The service did not provide a full range of treatments suitable to the needs of the patients or in line with national guidance about best practice. We observed care being delivered which did not align with nationally recommended practice for the treatment of eating disorders. People using the service were not receiving adequate psychological therapies to support their recovery. Relatives and stakeholders had raised concerns about some people not progressing during their admission. Due to the staffing pressures and the complex needs of the patients, staff did not have the capacity to adequately engage in clinical audit to evaluate the quality of care they provided.
  • Managers did not consistently ensure that staff received adequate training, supervision or appraisal. Staff did not always engage effectively with those outside the ward who would have a role in providing aftercare.
  • Staff did not always treat patients with compassion and kindness, respect their privacy and dignity, or understand their individual needs. Staff did not consistently involve patients and their families in care decisions.
  • People told us that they felt bored and that there was little to do at the hospital. We did not observe many organised activities taking place during our inspection.
  • Admissions and discharges were not always managed well, which resulted in additional pressures on the ward staff.
  • Governance processes did not identify some of these significant shortfalls in the care provided at the hospital and staff did not feel well supported by senior managers.

However:

  • The ward environments were safe and clean.
  • Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
  • People were receiving meaningful support from the dietetic team.
  • Senior managers had started a number of improvement projects including the creation of patient inclusion lead and autism champion posts

Letter from the Interim Chief Inspector of Adult Social Care and Integrated Care, James Bullion:

I am placing the service into special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate overall or for any key question or core service, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary another inspection will be conducted within a further six months, and if there is not enough improvement, we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.

A final version of this report, which we will publish in due course, will include full information about our regulatory response to the concerns we have described

23, 24, 25 May

During a routine inspection

Our rating of this location went down. We rated it as requires improvement because:

  • The service did not have enough staff, who knew the children and young people well and received basic training and induction to keep people safe from avoidable harm. The hospital relied on agency staff but did not always ensure they were well trained. One agency member of staff had not received a proper induction and some did not have experience, or training, in working with patients with mental health problems and eating disorders. Some patients had to wait for assistance with personal care or for naso-gastric feeding because staff were too busy supporting other patients.
  • Young people did not always get regular time with their named nurse.
  • The service did not always have a qualified nurse on shift on both wards at all times.
  • Not all clinic rooms were tidy. The clinic room on Aztec ward was cluttered with boxes of equipment on the examination couch. The clinical waste bin did not shut properly. These issues were similar to what we found at our last inspection.
  • Care plans did not reflect children and young people's assessed needs, and were not always personalised, holistic and recovery oriented. 4 out of 5 care records we reviewed were not up to date.
  • Managers did not make sure that they had staff with the range of skills needed to provide high quality care. They did not support staff with appraisals, supervision and the opportunity to learn via team meetings.
  • The service did not plan and manage the discharge of children and young people well as there were no clear plans in place which showed when patients could be expected to be discharged.
  • The service was not well-led. A number of issues raised at our last inspection had not been resolved including the clinic room on Aztec ward, agency staff training, and staffing levels.
  • Governance processes were not effective, and audits did not always identify areas for improvement. The provider had not recognised several of the issues we found during the inspection.
  • The provider had not ensured that staff had access to historical information on the new electronic care records system.
  • Despite training being available, staff were not always knowledgeable about how the Mental Capacity Act applied to their work and they could not describe how they worked within the main principles of the Act. Managers did not audit compliance with the Mental Capacity Act.
  • Patients did not have open access to outside space because this space was shared with adults which meant that supervision was required.
  • Young people told us that although restraint was safe, not all staff carried it out consistently, because some agency staff were trained in different techniques.
  • Staff morale was poor. Permanent staff felt over worked, unsupported and unable to take breaks. Some staff had been asked to act up into senior positions without the necessary training and induction. There was a high turnover of staff, and the hospital ward manager posts were vacant

However:

  • The wards were safe and clean, well maintained and fit for purpose. Most patients and carers were happy about the quality of the facilities. The food on offer was high quality and varied enough to meet each patient’s preferences.
  • Medicines management had improved, and regular physical health monitoring was well embedded, especially for patients with complex needs. Staff followed good practice with respect to safeguarding.
  • The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents thoroughly and shared lessons learned with the whole team and the wider service.
  • The staff team included a full range of specialists including consultants, doctors, psychologists, an occupational therapist, a speech a language therapist, a dietitian, and a specialist learning disability nurse. The hospital had a lead for autism, senior support workers and activity co-ordinators to support patients in building their skills and confidence.
  • Feedback from all the patients and carers we spoke with confirmed that permanent staff treated patients with compassion and kindness, respected their privacy and dignity, and understood their individual needs. They actively involved young people and their families in care decisions and kept them informed of significant events.
  • Feedback from most of the patients we spoke with confirmed that patients were making good progress towards their recovery goals. The hospital had developed a step-down facility to support patients that were not ready to be discharged but did not require hospitalisation. This was not yet operational when we inspected the service. Staff made adjustments for young people with disabilities and other specific needs. All the patients who required it had a communication passport in place.

13 September 2022

During an inspection looking at part of the service

We undertook an inspection of Ellern Mede Moorgate due to concerns being raised with the Care Quality Commission about the service. This inspection was focused on the safe key question. During the review of the evidence from the inspection, a regulatory breach was identified in the well-led key question.

Following this inspection our rating of safe, well-led and the overall rating of this location went down. We rated it as requires improvement because:

  • The service did not have enough registered nurses and nursing assistants to ensure that patients got the care and treatment they needed. Staff and patients reported concerns about staffing levels as it impacted on therapeutic work and activities being delivered to patients. Staff morale was impacted by the levels of restraint used and acuity of the service.
  • Staff used high levels of restraint due to the complex needs of the children and young people. The recording of restraint was not always detailed and in line with the requirements. Staff reported that they did not always feel confident in the techniques of restraint that they were required to use when restraining specific patients.
  • The service had a significant backlog of incidents that were awaiting review by the manager. It was not clear how managers were assured that these incidents had been managed appropriately. Managers had not been able to identify learning and themes from these incidents. Incidents on the reporting system were not always detailed or comprehensive.
  • Issues were identified with the management of medication and the clinic room on Aztec ward. This included staff not being aware of what was in the controlled drugs cupboard and issues with accessing the cupboard on Aztec ward. There was some expired medication and the sharps bin had not been signed and dated when opened. There were also some gaps in fridge temperature recording and some missed signatures on one patient’s medication chart.
  • Issues identified during the inspection indicated that the service’s governance processes were not always effective.

However:

  • The ward environments were safe and clean. Staff assessed and managed risk well. They followed good practice with respect to safeguarding.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients in care decisions.
  • Managers were aware of issues within the service and were making plans or starting to take action to ensure that these were addressed in a timely manner. Managers were open and honest about the issues they had identified.

22 and 23 June 2021

During a routine inspection

This was the first inspection of this location. We rated it as good because:

  • The service provided safe care. The ward environments were safe and clean. The wards had enough nurses and doctors. Staff assessed and managed risk well. They minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding.
  • Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
  • The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received training, supervision and appraisal. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.
  • Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They followed good practice with respect to young people’s competency and capacity to consent to or refuse treatment.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
  • Staff planned and managed discharge well and liaised well with services that could provide aftercare. As a result, discharge was rarely delayed for other than a clinical reason.
  • The service was well led, and the governance processes ensured that ward procedures ran smoothly.