Care Quality Commission finds that Oxford Health NHS Foundation Trust requires improvement

Page last updated: 12 May 2022

England's Chief Inspector of Hospitals has told Oxford Health NHS Foundation Trust that it must improve the quality of some of its services following an inspection by the Care Quality Commission.

Overall the trust has been rated as Requires Improvement. Staff were caring, compassionate and treated people with dignity and respect but although the trust provided some good services, improvements were needed for services to be consistently safe and effective.

Oxford Health NHS Foundation Trust provides health and social care, including mental health and other specialist services, to people across Oxfordshire, Buckinghamshire, Milton Keynes, Berkshire, Swindon, Wiltshire, Bath and North East Somerset (BaNES).

During the inspection in September and October a team of inspectors and specialists including doctors, nurses, allied health professionals, and experts by experience visited all the wards in community hospitals and the mental health inpatient units. They also visited and inspected another 52 locations where community health and community mental health services were delivered. The team spoke to more than 340 patients, relatives and carers and interviewed 534 members of staff. Full reports on all core services are available on this website.

Dr Paul Lelliott, CQC’s Deputy Chief Inspector of Hospitals (and lead for mental health), said:

“Our inspection found that there was a variation in the quality of the services provided by Oxford Health NHS Foundation Trust. We were concerned about the quality of the assessments of risks to people who use some of the child and adolescent mental health services. We found some ward environments that were outdated for the delivery of modern mental health. This was of particular concern at the Warneford Hospital. There was variability across the trust in their ability to respond to people in a timely way; with long waiting lists (up to 12 weeks) for specialist services in community health teams from referral to first appointments.

"However, we rated ten of the trust’s 15 core services as good and one as outstanding. The trust achieved ratings of outstanding for caring in child and adolescent community services and primary medical services and outstanding for responsive in forensic inpatient services and in primary medical services. In these domains, these services were able to demonstrate excellent practice and innovation which went above the standards expected.

“People are entitled to receive treatment and care in services which are consistently safe, effective, caring and responsive to their needs. We will return in due course to check that the improvements that we have identified have been made”.

Overall CQC rated safe as requires improvement. Inspectors found pockets of poor practice which must be addressed. The most concerning of these were poor risk planning in some areas of children’s services, unidentified ligature points in acute mental health services and a lack of basic life support training for administrative and reception staff in primary medical services.

We rated community health services for children and young people as outstanding. Some aspects of child and adolescent community services, and forensic inpatient services, demonstrated excellent practice and innovation which went above the standards expected.

In primary medical services, inspectors found that not all staff had received training in basic life support. There were occasions when only a GP and member of reception staff were on duty. This meant that only the GP was trained to deal with emergencies. The non-clinical staff had requested basic life support training for reception and admin staff but they had been informed that it was not trust policy to offer this training to non-clinical staff.

In community mental health services the trust had set up a street triage team which had helped contribute to a 67% reduction in the use of police custody as a place of safety over the last 12 months and a 50% reduction in the number of people detained by police under the Mental Health Act.

The Care Quality Commission has identified a number of areas for improvement, including:

  • In community end of life care services, the trust must review how they assess patients’ needs and deliver care and treatment in line with evidence based guidance.
  • ​In community mental health services for children and young people, the trust must ensure that all risks to young people are properly recorded 
  • ​In community-based mental health services for adults of working age, the trust must ensure that patients have access to psychological therapies within a reasonable time.

The reports highlight a number of areas of good practice including:   

The trust had very effective out of hours provision for young people who may be in crisis. 

  • The trust worked well with other agencies in the youth offending service in Oxfordshire running an innovative cannabis clinic. 
  • The police gave warnings on possession and staff triaged young people for developing mental health problems and provided education on the risk of illicit substance misuse to mental health.
  • The community nursing service was skilled at engagement with hard to reach groups such as the traveller community.  Inspectors found good engagement and a respect for this group’s specific cultural needs from community nurses.

On Friday 29 of January the Care Quality Commission will present its findings to a local Quality Summit, including NHS commissioners, providers, regulators and other public bodies. The purpose of the Quality Summit is to develop a plan of action and recommendations based on the inspection team’s findings.


For further information please contact CQC Regional Engagement Manager, John Scott on 07789 875809 or, for media enquiries, call the press office on 020 7448 9401 during office hours.  Journalists wishing to speak to the press office outside of office hours can find out how to contact the team here. (Please note: the duty press officer is unable to advise members of the public on health or social care matters). For general enquiries, please call 03000 61 61 61.

About the Care Quality Commission

The Care Quality Commission (CQC) is the independent regulator of health and social care in England.

We make sure health and social care services provide people with safe, effective, compassionate, high-quality care and we encourage care services to improve.

We monitor, inspect and regulate services to make sure they meet fundamental standards of quality and safety and we publish what we find to help people choose care.