CQC rates Rotherham care service inadequate

Published: 24 April 2024 Page last updated: 24 April 2024

A care service in Rotherham, has been rated inadequate by the Care Quality Commission (CQC) and placed in special measures, following an inspection carried out in January.

Ellern Mede Moorgate, run by Oak Tree Forest Limited, is a hospital which provides specialist eating disorder services for children and young adults. It provides treatment for up to 12 people.

The inspection was prompted due to concerns received about the quality of care and the safety and wellbeing of the young people using the service.

Following this inspection, the hospital’s overall rating has dropped from requires improvement to inadequate as has its rating for being safe and well-led. The rating for how caring it is has dropped from good to inadequate. How effective and responsive it is remains rated requires improvement.  

The service has been placed in special measures, which means it will be kept under close review by CQC to keep people safe and to check sufficient improvements are being made. If CQC doesn’t see rapid and widespread improvements, further action will be taken.

Alan Stephenson, CQC deputy director of operations in the north, said:

“When we inspected Ellern Mede Moorgate, it was concerning to see the lack of strong leadership displayed by the provider, Oak Tree Forest Limited and the culture they created didn’t enable staff to deliver high-quality care.

“Young people told us they didn’t always feel safe, which they raised with staff repeatedly. We found that this was partly because staff didn’t always record risks to people or take timely action to reduce those risks.

“Young people also told us physical restrictions were used too often and that they’d been injured or experienced pain during these. When we looked at the home’s care records we found levels of restrictive interventions were high. Records showed that, in 12 months there were over 5,000 instances of physical restraint at the hospital.  We were also concerned that some restrictions, for example, access to bedrooms during daytime hours, were used to manage behaviour, rather than help people. Staff told us that they didn’t feel they had enough training and support in relation to the physical restraints they were expected to do as part of their role.

“Although staff provided physical care and treatment for the people using the service, staffing vacancies resulted in the children and young people not having enough access to psychological therapies to support their recovery. For example, the hospital stated that young people would receive psychotherapeutic interventions, but there was no group therapy taking place and most of the young people were also not receiving any regular individual therapy.

“Additionally, we found staff didn’t always give children and young people help, emotional support and advice when they needed it because of these staffing challenges. We saw staff were sometimes too busy to offer them emotional support. The young people we spoke with said they didn’t feel like staff had time for them and they struggled to build relationships with them due to the high number of agency staff working at the service.

"We have told Ellern Mede Moorgate where we expect to see rapid and widespread improvements and will continue to monitor them closely to keep people safe while this happens. We will return to check on their progress and won’t hesitate to take action if people are not receiving the care they have a right to expect.”

Inspectors found:

  • The wards did not have enough nurses and reliance on agency workers was high
  • We observed care being delivered which did not align with nationally recommended practice for the treatment of eating disorders
  • 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 people using the service, staff did not have the capacity to adequately engage in clinical audit to evaluate the quality of care they provided
  • 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
  • Staff did not feel well supported by senior managers.


  • The ward environments were safe and clean
  • Senior managers had started a number of improvement projects including the creation of patient inclusion lead and autism champion posts.

The report will be published on CQC’s website on Wednesday 24 April.

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.