Queensway Hospital Also known as Oak Tree Forest Limited

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 meant people were safe and protected from avoidable harm.

Good: All wards were safe, clean well equipped, well furnished, well maintained and fit for purpose. Staff assessed and managed risks to patients and themselves well. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. The service used systems and processes to safely prescribe, administer, record and store medicines. The service managed patient safety incidents well.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

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. 

The hospital recorded 1,288 incidents from July 2025 to June 2026 which included incidents documented as self-harm, violence and aggression, medication, health and safety incidents and nasogastric (NG) feeds (which is the delivery of liquid formula, fluids, or medications directly into the stomach via a thin, flexible tube passed through the nose and oesophagus.) Where patients required NG feeds to meet their nutritional requirements these were always recorded as an incident and accounted for half of the recorded incidents. The service de-briefed after each NG session to enable patients to give ongoing feedback in terms of the experience and make changes requested.

The provider followed the Patient Safety Incident Response Framework (PSIRF) which sets out the NHS’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents for the purpose of learning and improving patient safety. This involves all professions to develop psychologically safe cultures and flexible and transparent approaches to learning responses and investigation.

Staff were debriefed and received support after a serious incident. Staff we spoke with told us about a patient safety incident during a period of escorted leave. As a result of this the hospital had learnt a lesson to ensure input from the whole team in the pre-leave risk assessment, which had been updated to reflect this.

Staff received feedback from investigation of incidents, both internal and external to the service and there was evidence that changes had been made as a result of feedback. The service received complaints from patients regarding staff sleeping on a night shift. Two patients also spoke with us about these concerns. As a result of these safety concerns the hospital had introduced an extra nurse on night shifts to undertake regular reviews and audits and managers told us reports of staff sleeping on nights had reduced.

Staff understood the duty of candour. They were open and transparent and gave patients and families a full explanation if and when things went wrong.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The hospital had a referrals policy which ensured that all essential information about the patient was received to determine if the patient’s needs could safely be met. All patients referred had their personalised package of care agreed with commissioners prior to admission and case managers managed and reviewed this regularly. Commissioners we spoke with told us that the hospital supported the transition between children and adult’s services “safely, effectively and in a person-centered way that met their complex needs whilst involving the family”.

Staff involved all the necessary healthcare and social care services to ensure patients had continuity of safe care, both within the service and post-discharge.

During our inspection we observed multi-disciplinary team meetings and these included care coordinators and future care providers to ensure continuity of care.

We scored the service as 2. The evidence showed some shortfalls. The service had 2 restrictions recorded on their blanket restrictions log which did not appear proportionate. However, the service did work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. 

The hospital had a blanket restrictions log which covered restrictions such as to laundry facilities, internet-enabled devices were to be used in accordance with individual care plans and hospital policy, no plastic bags could be used and access to the occupational therapy kitchen was only allowed following completion of an individual risk assessment. 

During the inspection, we identified blanket restrictions that were recorded on the blanket restrictions log, including limitations on access to the garden and direct access to hot and cold drinks. We were not assured these restrictions were proportionate to individual needs and risks. Hospital leaders told us that access to the garden could be restricted following an individual risk assessment and confirmed that all other patients should have unrestricted access. Patients were regularly offered drinks and provided with water jugs. One patient told us they were able to complete their own shopping and access refreshments. Following our feedback, the hospital reviewed these restrictions, introduced direct access to drinks, and permitted garden access unless restricted through an individual risk assessment.

Staff were trained in safeguarding adults, children and adolescents and at the time of inspection staff were 97% compliant with this training, which was in line with the intercollegiate guidance for adult safeguarding roles and competencies for health care staff. 

Staff knew how to make a safeguarding alert and did so when appropriate. The hospital had made 13 safeguarding referrals to the local authority in the 12 months prior to our inspection. 

Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act. 

Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies. 

Staff followed safe procedures for children visiting the service. The visiting room was accessible from the reception, so children did not have to enter the ward environment. 

Mental Capacity Act

97% of staff had had training in the Mental Capacity Act.

Staff had a good understanding of the Mental Capacity Act, in particular the five statutory principles

There were 0 deprivation of liberty safeguards applications made in the 12 months prior to our inspection to protect people without capacity to make decisions about their own care. 

The provider had a policy on the Mental Capacity Act, including deprivation of liberty safeguards. Staff were aware of the policy and had access to it.

Staff knew where to get advice from within the provider regarding the Mental Capacity Act, including deprivation of liberty safeguards.

Staff took all practical steps to enable patients to make their own decisions

For patients who might have impaired mental capacity, staff assessed and recorded capacity to consent appropriately. They did this on a decision-specific basis with regard to significant decisions.

When patients lacked capacity, staff made decisions in their best interests, recognising the importance of the person’s wishes, feelings, culture and history.

The service had arrangements to monitor adherence to the Mental Capacity Act.

Staff audited the application of the Mental Capacity Act and took action on any learning that resulted from it.

We scored the service as 3. The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. Staff assessed and managed risks to patients and themselves well and followed best practice in anticipating, de-escalating and managing behaviour.

Staff used restraint only after attempts at de-escalation had failed. The ward staff participated in the provider’s restrictive interventions reduction programme. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The hospital recorded 1,913 incidences of restrictive interventions from July 2025 to June 2026 and 3 of these involved restraint in the prone (face down) position and repositioned as quickly as possible.  When patients posed a potential risk of harm to themselves or others the hospital would use restrictive interventions, for as short a time as possible, to mitigate these risks. Multiple restrictive interventions could relate to the same incident and a review of incidents showed the staff focused on least restrictive interventions and attempted deescalation first. The hospital recorded any restrictive practice required to administer an NG feed and every instance would be recorded, including low level support techniques such as hand support. The hospital recorded 5 instances of rapid tranquilisation by injection in the 12 months prior to our inspection.

The organisation employed a consultant for the prevention and management of violence and aggression who regularly visited the hospital and carried out scenario-based workshops with the staff depending on the needs of the individual patients. The hospital was a member of the restraint reduction network and staff attended regular meetings. The hospital regularly reviewed episodes of restrictive practice in multidisciplinary team meetings, care and treatment reviews, patient safety meetings and risk management meetings. 

Staff involved patients in care planning and risk assessment which we saw in our review of 5 care records. Patients were invited to attend, and their requests were discussed in multidisciplinary team reviews which we observed, and patients told us they had access to a copy of their care plan. The service completed a form for patients that required an NG feed and this form included why the NG feed was necessary, the plan to move away from this, the opinion of the home team (for out of area patients) and parents or significant relatives’ opinion and ensured a trauma informed approach to any need for restrictive interventions. 

Staff communicated with patients so that they understood their care and treatment, including finding effective ways to communicate with patients with communication difficulties. The organisation had an autism lead who visited the hospital fortnightly and the hospital had recently introduced an autism champion role. Patients we spoke with were positive about the support provided by these roles. 

Staff ensured that patients could access advocacy. 

We scored the service as 2. The evidence showed some shortfalls. The service did not always ensure they detected and controlled all potential risks in the care environment. 

The layout of the hospital provided 12 individual ensuite bedrooms. Six of these were on the ground floor and 6 were on the first floor, accessible by stairs or a lift. There were 2 small lounges for patients to use on the first floor and a room for nasogastric feeding. 

On the ground floor the hospital had a communal dining room and communal lounge. The hospital had a kitchen for patients to undertake activities of daily living, a social space for crafts and games, a multi faith room and a garden. There was also a family room and multi-purpose room separate from the ward area. 

The hospital had an up-to-date fire risk assessment in place and fire drills were undertaken in line with policy. The hospital had implemented an action plan following the fire risk assessment. Some recommended actions were still in progress and the hospital had a phased programme of work to complete the actions. The service had added this to the services risk register until completed. 

Personal emergency evacuation plans (PEEPs) were completed for 8 out of 9 patients which we reviewed, and the hospital completed a plan for the remaining patient during our inspection. We fed back to the hospital that actions to be taken if a patient refused to leave the building needed to be clearer and this was accepted by the hospital. The hospital had an evacuation chair in situ and staff confirmed training in this.

Patients had easy access to nurse call systems and during our inspection all staff had access to alarms and told us they felt safe within the environment. However, we were told by one member of staff that sometimes there were not sufficient working alarms for all staff and that the alarms did not always sound in all ward areas. Evidence provided by the hospital showed regular checks of the alarm system were undertaken and hospital had requested quotes to improve the alarm system. 

Clinic rooms were equipped with accessible resuscitation equipment and emergency drugs. Both wards had an emergency red bag which contained some emergency medication, a green bag and another red emergency drugs bag. The hospital had a daily clinic check sheet and a weekly emergency bag check. However, we observed there were several gaps in the daily clinic sheet on Elizabeth upper ward and no calibration records for the blood monitoring machine for testing blood sugar levels. We also noted adrenaline expired in May 2026 in the red bag on Elizabeth lower ward. The ward manager informed us they had new adrenaline available but recognised the process of replacing this needed to be reviewed to ensure it was replaced prior to the expiry date. 

Staff did regular risk assessments of the care environment. Where there were potential ligature anchor points the hospital mitigated the risks adequately. 

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.

Managers calculated the number and grade of nurses and support workers required and the hospital manager could adjust staffing levels to take account of patient need and observation levels. Based on occupancy at the time of our onsite inspection there were 5 nurses and 24 healthcare assistants on a day shift and 3 nurses and 22 healthcare assistants on a night shift.

A qualified nurse was always present in communal areas of the ward.

Staffing levels allowed patients to have regular one-to-one time with their named nurse.

Staff shortages rarely resulted in staff cancelling escorted leave or ward activities. There were enough staff to carry out physical interventions (for example, observations and restraint) safely and staff had been trained to do so.

Staff told us they completed training and overall training compliance was 96%; all courses were above 86% compliant. This included Immediate / Intermediate Life Support (ILS), which was 100% compliant at the time of our inspection.

The service had 11.4 whole time equivalent current vacancies, including a 0.2 physiotherapist, 0.6 dietetic assistant and social worker, 5 healthcare assistants and 5 registered mental health nurses. Due to high levels of staffing requirements for individual patients, the hospital deployed agency and bank nursing staff to maintain safe staffing levels. The hospital regularly reviewed staffing levels and reduced agency and bank staff accordingly. When agency and bank nursing staff were used, those staff received an induction and most of the agency staff used were familiar with the hospital.

During our inspection we were made aware of concerns relating to the organisation’s sponsorship license. The hospital were managing any risk to the continuity of care for patients whilst also supporting the members of staff who had been internationally recruited. The hospital informed us they had several staff currently going through on-boarding and awaiting start dates, which would in turn reduce the vacancies.

The hospital reported the average monthly staff turnover rate in the 12 months prior to inspection as 3%. The average monthly sickness absence over the same period was 1%.

There was adequate medical cover day and night and a doctor could attend the ward quickly in an emergency.

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Staff maintained equipment well and kept it clean. Any ‘clean’ stickers were visible and in date.

All ward areas were clean, had good furnishings and were well-maintained. All relatives we spoke with told us that they found the environment to be clean, well maintained and welcoming. A relative told us that when they visited on a weekend a cleaner was “delightful” and recommended somewhere to take their relative in the area.

Cleaning records were up to date and demonstrated that the ward areas were cleaned regularly.

Staff adhered to infection control principles, including handwashing and 90% of staff had completed hand hygiene training.

We scored the service as 2. The evidence showed some shortfalls. The service did not always follow clear processes to make sure that medicines and treatments were safe. However, they made sure that treatment met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

We reviewed 9 prescription charts. We identified 1 error regarding a change to a patients medication which was not identified on the T3 form (used when a detained patient either cannot consent to, or has not consented to, specific medical treatment for mental disorder). This was immediately rectified by the hospital by completing a section 62 monitoring form. However, we found that staff reviewed the effects of medication on patients’ physical health regularly and in line with National Institute for Heath and Care Excellence (NICE) guidance, especially when the patient was prescribed a high dose of antipsychotic medication. We saw no evidence of overprescribing and there was a good awareness and clear recording of any patient’s allergies.

Staff followed good practice in medicines management (that is, transport, storage, dispensing, administration, medicines reconciliation, recording, disposal, use of covert medication) and did it in line with national guidance. We noted that photographs were not present on medication charts which we fed back to the hospital to consider as good practice. Following our inspection the hospital informed us they had added photographs, in line with patient consent.