Queensway Hospital Also known as Oak Tree Forest Limited

On this page

• 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 meant the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

Requires improvement: Governance processes did not always operate effectively and audits did not always identify issues and provide assurance. However, leaders had the skills, knowledge and experience to perform their roles. Staff knew and understood the provider’s vision and values and how they applied to the work of their team. Staff felt respected, supported and valued. Teams had access to the information they needed to provide safe and effective care. Staff collected analysed data about outcomes and performance. They used this to identify improvements.

We have not awarded this service a score for Well-led.

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

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.

Staff knew and understood the provider’s vision and values. The providers core values were kind and caring, honesty and integrity, respect and dignity, professionalism, team player and robust and they knew how they were applied in the work of their team.

Staff had the opportunity to contribute to discussions about the strategy for their service, especially where the service was changing. Since the last inspection the service had undergone a change in terms of the service provision. Staff were fully involved in this transformation, and the service was temporarily closed for a period of time to ensure staff had the appropriate training and support to deliver the new service.

External partners and relatives that we spoke with told us they were able to raise any challenges they encountered or concerns they had, and this was met with understanding.

Leaders and managers could explain how they were working to deliver care within the budgets available. Staff shared with us their project plans for a sensory room and an American Diner experience in collaboration with patients. The hospital were also in the early stages of designing plans to convert another building on the site to provide step down support for patients transitioning from inpatient care to community living through structured routines, skill development, and therapeutic engagement.

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.

Leaders had the skills, knowledge and experience to perform their roles. Leaders had a good understanding of the hospital. They could explain clearly how the teams were working to ensure good care and discussed improvements being made to improve outcomes for people who use the service.

Leaders were visible in the service and approachable for people and staff. All staff we spoke with told us that the hospital manager was approachable and supportive. The clinical operations director, medical director and chief operating officer also visited the service.

Leaders were managing the concerns relating to the organisation’s sponsorship license well. Leaders had been open and transparent with the staff, patients, families and commissioners.

Leadership development opportunities were available, including opportunities for staff to develop professionally. The organisation enabled study days and attendance at conferences.

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.

The organisation had a Freedom to Speak Up Guardian (FTSUG) which the staff we spoke with were aware of. Following the last staff survey in 2025 whereby communication had been an area for improvement, actions had been taken to strengthen supervision and feedback processes, evidencing concerns were acknowledged and acted upon. All staff we spoke with during inspection told us that the hospital fostered a positive culture where concerns would be listened to and heard. They told us supervision, meetings, reflective practice sessions and post incident de-briefs were all positive and supportive. 

Patients and carers were involved in decision-making about changes to the service. The hospital supported patient inclusion and patients had the opportunity to meet with the expert by experience monthly and attend weekly community meetings. The ex-patient group were invited to a fortnightly meeting to feedback on their experiences and could continue to attend as long as they wanted to. 

Patients and staff could meet with members of the provider’s senior leadership team to give feedback and relatives we spoke with confirmed this. 

Managers and staff had access to the feedback from patients, carers and staff and used it to make improvements. For example staff told us if they asked for items or community activities that would benefit the patients these requests were supported.

Patients and carers had opportunities to give feedback on the service they received in a manner that reflected their individual needs. The most recent family and carer satisfaction survey was completed in 2025 but responses to this were limited due to the number of patients accessing the service at that time. Communication was identified as an area for improvement. The hospital already had an action plan in place focused on strengthening processes for providing regular updates and ensuring clear points of contact. However, it was apparent this still required some attention and action as 2 relatives we spoke with during the inspection gave examples where they felt communication could have been better. The other 3 relatives we spoke with felt communication needs were being well met. 

We scored the service as 3. The evidence showed a good standard. The service valued diversity in their workforce. The service worked towards an inclusive and fair culture by improving equality and equity for people who work for them.

Staff we spoke with felt managers were respectful of cultural diversity. Staff told us if they experienced any racist comments they were fully supported. Cultural work had been undertaken to reduce these incidents and to improve awareness, understanding and respect for cultural differences.

Staff told us they were supported and were able to apply to work flexibly to account for personal circumstances such as caring responsibilities and health issues. Staff told us that managers put reasonable adjustments in place for staff members to help them conduct their role. Staff had access to a wellbeing app.

The provider undertook equality monitoring of staff within the service to ensure it was diverse in its make-up. The service supported an expert by experience to hold patient groups within the service.

We scored the service as 1. The evidence showed that some governance process did not always operate effectively. However, the service did have clear responsibilities, roles and systems of accountability. They did act on information about risk, performance and outcomes.

Our findings from other key questions demonstrated that some governance process did not always operate effectively.

Staff undertook or participated in local clinical and environmental audits. However, the audits did not always identify issues and provide assurance. We identified a missing PEEP for 1 patient and 1 member of staff told us that in some areas of the ward it was difficult to hear the alarm. There were some missing checks on the daily clinic check sheet on Elizabeth upper ward, we found adrenaline expired in May 2026 in the emergency red bag on Elizabeth lower ward and there were no calibration records for the blood monitoring machine. The mental health act administrative audit had not picked up on a discrepancy between a prescription chart and the T3 form. 

Although the service strived to achieve effective person centred care we found that there was some inconsistent use of preferred pronouns that care record audits had not identified. We also received feedback that although patients were involved in creating their care plans these were not consistently followed by all staff.

Information was in an accessible format, however feedback from some relatives and advocates highlighted that communication could be improved. The hospital had identified communication as an area for improvement and had an action plan in place at the time of inspection. 

However, there was a clear framework of what must be discussed in meetings to ensure that essential information, such as learning from incidents and complaints, was shared and discussed. We reviewed monthly quality and governance reports and team meeting minutes which included clinical governance updates. 

Staff implemented recommendations from reviews of incidents, complaints and safeguarding alerts at the service level. We saw evidence of this during our inspection. 

Staff understood the arrangements for working with other teams, both within the provider and externally, to meet the needs of the patients. We received feedback from commissioners and external partners who told us that the hospital “proactively invite community stakeholders to all relevant meetings” and “care is coordinated between external teams and visits by care coordinator and other care facilitators and solicitors are maintained.”

Staff maintained and had access to the risk register, and we reviewed this as part of the inspection and concerns matched those on the risk register. Staff could escalate concerns when required. 

The service had business continuity plans in place for emergencies. 

The service used systems to collect data. Team leaders had access to information to support them with their management role. This included information on the performance of the service, staffing and patient care. 

Staff had access to the equipment and information technology needed to do their work. The information technology infrastructure, including the telephone system, worked well and helped to improve the quality of care. 

Information governance systems included confidentiality of patient records. 

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.

The hospital had good working relationships with external providers such as commissioners, safeguarding, advocacy and community teams. We received feedback from external partners, which was positive, and they told us about collaborative working to support people who use the service. Commissioners told us information was received in a timely manner, but advocates said there could be some improvements to gaining and receiving information and felt this was a work in progress.

Directorate leaders engaged well with external stakeholders such as the Care Quality Commission, commissioners and Healthwatch.

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.

Staff were given the time and support to participate in development and research.

Staff used quality improvement methods and knew how to apply them. We spoke with members of the multi-disciplinary team who were keen to be involved in quality improvement initiatives. For example, the psychologist told us about training sessions for staff in terms of communicating, supporting diagnosis, trauma and trauma informed work, attachment issues and how this presents in people and the RAID approach (Reinforce Appropriate, Implode Disruptive) which is a psychological approach designed to reinforce positive behaviours and minimise or displace negative ones. The dietician we spoke with was involved in writing papers and guidelines regarding least restrictive practices and had implemented these approaches within the hospital.

Staff participated in national audits relevant to the service and learned from them. For example, the hospital was working towards benchmarking and quality improvement initiatives such as the Triangle of Care (a quality improvement scheme for health and social care providers that promotes safety, recovery and wellbeing by including and supporting unpaid carers) and the hospital was also working towards an autism accreditation and had submitted the assessment in May 2026.