Oxford Health NHS Foundation Trust

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• 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 means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of regulation 12 (safe care and treatment) and regulation 13 (safeguarding service users from abuse and improper treatment).

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Quality Statement Score: 2

We scored the service as 2. The evidence showed some shortfalls. The service did not always have a proactive and positive culture of safety based on openness and honesty. Lessons were not always learned to continually identify and embed good practice.

There had been no serious incidents during the 12 months prior to the inspection that required investigation in line with the Patient Safety Incident Response Framework (PSIRF).

Between 1 August 2025 and 31 October 2025 staff reported 821 incidents, most of which were categorised as ‘no harm’ or ‘low harm’. The most common types of incidents were violence and self-harm. Three incidents had been categorised as causing ‘moderate harm’. Managers attended a weekly safety meeting to discuss any incidents which had been categorised as resulting in moderate harm or higher.

Staff we spoke with told us they knew what incidents to report and how to report them. However, they did not always report all incidents that they should. For example, not all instances of the administration of rapid tranquilisation had been reported in line with Trust policy. This meant that the incident would not be reviewed and opportunities for learning were missed. It also meant that data around the number of incidents of the administration of rapid tranquilisation may not be accurate as not all incidents had been recorded. Rapid tranquilisation is the use of medication by the parenteral route (usually intramuscular or, exceptionally, intravenous) if oral medication is not possible or appropriate and urgent sedation with medication is needed (NICE guidance NG10, 2015). We also found instances where incidents had been inappropriately categorised. For example, an incident involving a young person self-harming and being taken to AE to have a wound stitched had been categorised as ‘no harm’.

When staff reported incidents, these were then sent to managers for review. Managers on all wards had high numbers of incidents still awaiting review – 190 on Highfield unit, 37 on Meadow unit and 54 at Marlborough House. The oldest one of these was from 2024. Managers told us that they received emails whenever any incident forms were submitted and that they would ensure appropriate action was taken, but they did not have time to update the incident reporting system to reflect this.

Staff understood the duty of candour. They were open, transparent and gave patients and families a full explanation if and when things went wrong. Duty of candour was a required section to complete on incident forms.

There was evidence that changes had been made as a result of learning from incidents. For example, staff on Meadow unit had implemented a medication handover checklist to try and reduce medicines errors.

Staff were invited to attend regular learning from incident meetings. These provided staff with the opportunity to reflect on incidents and receive support from peers.

Staff were debriefed and received support after a serious incident. Staff told us they felt well supported following incidents and were given time off to recover if they had been physically injured. However, some staff on Meadow unit told us they did not have enough time to reflect following incidents. The provider had organised separate debrief sessions for staff who had been seriously injured during assaults. Psychological support for staff had been offered via Trauma Risk Management (TRiM). TRiM is a peer support system for people working in high risk environments, focusing on early intervention and ongoing support. Managers told us they had set up a working group to reduce violence and aggression towards staff. A quality improvement (QI) project had been initiated focusing on reducing violence and aggression towards staff. Areas of learning had been identified, although they had not yet been completed. However, none of the staff we spoke with were aware of this working group.

Quality Statement Score: 3

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 service’s referral and admission processes ensured that all essential information about the patient was received to determine if the patient’s needs could safely be met. All referrals to the service came through the Thames Valley single point of access. Staff completed comprehensive pre-admission assessments prior to accepting referrals.

Staff at Marlborough House had a good relationship with their local acute hospital. The hospital could provide secure transport, or staff could accompany young people using the hospital’s van. An allocated staff member remained with the young person while at the hospital.

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

Quality Statement Score: 2

We scored the service as 2. The evidence showed some shortfalls. The service did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always 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 service had high use of restrictive practices, and it was not always clear that de-escalation had been attempted prior to young people being restrained.Two young people reported negative experiences during restraint.

There were blanket restrictions in place on all 3 wards. Young people were unable to access snacks and drinks without staff intervention. The dining rooms on all wards were locked at various points during our inspection and we did not see evidence of risk assessments to determine the need for this restriction for all patients on the ward. On Highfield unit there were also no cups available in the dining room. Snacks were not readily available on any of the wards, unless it was set ‘snack’ time. All the young people we spoke with told us they had to ask staff for snacks and drinks. Three young people commented that this could take a considerable amount of time, especially if they were not on continuous observations so did not always have access to a member of staff to support them. The gardens on Meadow and Highfield units were also locked during the day and we did not see any evidence of this having been individually risk assessed as required. At Marlborough House the young people were able to collect items from their bedrooms during the day, but not permitted to stay in their bedroom if they wanted to. This resulted in conflict between the young people when they wanted to rest in the communal lounge whereas others wanted to watch television or listen to music.

Most staff were trained in safeguarding, knew how to make a safeguarding alert, and did that when appropriate. However, compliance with level 3 safeguarding children training and level 3 safeguarding vulnerable adults training was low across all 3 wards. At Marlborough House 76% of eligible staff had completed level 3 safeguarding children training and 50% had completed level 3 safeguarding vulnerable adults training. On Highfield unit 77% if eligible staff had completed level 3 safeguarding children training and 79% had completed level 3 safeguarding vulnerable adults training. On Meadow unit 72% of eligible staff had completed level 3 safeguarding children training and 66% had completed level 3 safeguarding vulnerable adults training.

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.

Each unit had designated safeguarding leads.

Staff told us they had access to a range of safeguarding resources on the intranet, and that they could always seek advice from senior colleagues such as a clinical lead or charge nurse.

Managers told us the Trust safeguarding team had been very supportive. Staff received safeguarding supervision 3 times a year, and the team had guidance for complex issues. A safeguarding consultation line was available. The patient safety team attended operations and governance meetings to provide safety updates.

If any allegations were made against staff, the Local Authority Designated Officer (LADO) process was followed.

Mental Capacity Act

All doctors and nurses received regular training in the Mental Capacity Act (MCA), including a mandatory two-hour session. External trainers attended to deliver this training.

Staff recorded competence and capacity during ward rounds every week within the case management notes.

Staff had a good understanding of the Mental Capacity Act, particularly the five statutory principles.

The provider had a policy on the Mental Capacity Act. Staff were aware of the policy and had access to it.

For young people 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 and this was recorded in their care records.

When young people lacked capacity, staff made decisions in their best interests.

Quality Statement Score: 1

We scored the service as 1. The evidence showed significant shortfalls. The service did not work well with people to understand and manage risks. They did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Staff did not always ensure they had attempted de-escalation prior to restraining young people.

The service had high use of restraint and restrictive practice, including prone restraint. Between 1 August 2025 and 31 October 2025 there were 689 restraints recorded, with 17 of these being in the prone position. A reducing restrictive practices report presented to the Quality and Clinical Governance Sub-Committee in July 2025 showed that approximately 40% of incidents resulted in young people being restrained. This report also highlighted that Highfield unit and Marlborough House fell in the upper quartile for restraints nationally. However, the report acknowledges that benchmarking is challenging due to inconsistencies in service models. The report outlined the measures taken by the trust to try and reduce the use of restrictive interventions but acknowledged that these measures had not been successful and the use of restrictive interventions had continued to increase. The trust had submitted a business proposal to the Provider Collaborative to try to obtain increased funding for Highfield unit and Marlborough House to enable staff to implement further measures to try and reduce levels of restrictive practice.

Records did not always show that staff had offered therapeutic interventions or attempted de-escalation before restraining young people or administering rapid tranquillisation. We observed a learning from incidents review meeting at Marlborough House. During this review, the staff did not refer to de-escalation at all. Senior members of the clinical team did not query staff about their lack of de-escalation attempts. The language that staff used during this review, such as ‘maxed a patient out’ on lorazepam and ‘restrained’ a patient into a room, was not in accordance with a therapeutic, least restrictive approach.

Three young people on Highfield unit and Marlborough House reported negative experiences when staff restrained them.

There were blanket restrictions in place on all 3 wards. This meant that all young people on the ward were subject to restrictions without individual risk assessments to justify their application. Young people were unable to access snacks and drinks without staff intervention. The dining rooms on all wards were locked at various points during our inspection. On Highfield unit there were also no cups available in the dining room. Snacks were not readily available on any of the wards, unless it was set ‘snack’ time. All the young people we spoke with told us they had to ask staff for snacks and drinks, and 3 young people commented that this could take a considerable amount of time, especially if they were not on continuous observations so did not always have access to a member of staff to support them. The gardens on Meadow and Highfield units were also locked during the day. At Marlborough House the young people were able to collect items from their bedrooms during the day, but not permitted to stay in their bedroom if they wanted to. This resulted in conflict between the young people when they wanted to rest in the communal lounge whereas others wanted to watch television or listen to music.

We reviewed 15 risk assessments and management plans during the inspection. Where risk mitigation plans were in place, these were not always effective. Between 1 August 2025 and 31 October 2025 there had been 9 incidents on Highfield unit where observations had been missed. In addition to this, young people told us that staff were often asleep or distracted while carrying out observations. The provider told us that they took action to investigate any allegations of staff sleeping whilst on shift. They also introduced staff wellbeing checks for staff carrying out one to one observations.

Staff told us that young people were searched when they returned from leave to ensure they were not bringing any contraband items onto the wards. However, at Marlborough House we found that searches had not been documented in 9 out of 10 cases. This meant that there was a risk that young people could bring items onto the ward which they could later use to harm themselves with.

Young people told us they did not feel involved in their care planning. They told us that staff wrote the care plans for them and then asked them to sign them.

Staff did not always carry out risk assessments prior to young people utilising Section 17 leave. We did not find evidence of this in any of the care records we reviewed. Staff did also not consistently document the times young people returned to the ward, which meant that staff could not be assured that young people had returned as expected.

Staff provided advocates with details of young people newly admitted to the wards. They also displayed information about advocacy in communal areas.

Quality Statement Score: 2

We scored the service as 2. The evidence showed some shortfalls. The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Ward layout did not allow staff to observe all parts of ward, however on Meadow unit Closed Circuit Television (CCTV) was in operation in communal areas. There were no CCTV or mirrors in place along the corridors on Highfield unit. Managers told us that staff presence was used to mitigate risk. Managers told us that they had requested mirrors and submitted a bid to have CCTV in communal areas following an allegation of abuse against staff.

Staff did not ensure that safe food hygiene practices were followed. For example, on Meadow unit and at Marlborough House we found open jars of food in the fridges that did not include any labels stating when they had been opened. On Meadow unit we also observed a staff member preparing food and carrying it, uncovered, to a young person’s bedroom.

The ward environment on Highfield unit was tired and in need of redecoration. Managers told us they had requested this but were unsure when this would be completed. The glass panels on some of the communal doors had been smashed and boarded up.

Staff on each ward had carried out ligature audits. These were completed at least annually, or more frequently, if there were any changes to the environment. Any identified ligature points had documented mitigation in place to manage the risk.

The wards complied with guidance on eliminating mixed-sex accommodation. The bedrooms on Meadow and Highfield units were en-suite and there were male and female only lounges. At Marlborough House the young people shared communal bathrooms but these were separated into male and female areas. There was a communal lounge and a quiet lounge which could be made into gender specific areas.

Where young people consented to this, staff utilised a visual based monitoring system in bedrooms, seclusion rooms and de-escalation rooms. This was switched on 24 hours a day and could monitor the pulse and respiration rate of young people and alert staff to any abnormalities. The provider had a clear policy in place around the use of this system, and staff provided young people with clear, easy to read information about its use.

Staff had easy access to alarms and young people on Meadow and Highfield units had easy access to nurse call systems. There were no nurse call buttons available in the bedrooms at Marlborough House. Staff told us that staff observations were used to mitigate this risk.

Seclusion rooms allowed clear observation and two-way communication and had toilet facilities and a clock. Marlborough House did not have any seclusion facilities. However, funding had been approved to build a high dependency unit on site.

Clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly. In the clinic room on Highfield unit there was an item of ophthalmology equipment with frayed and exposed wiring. This was fed back to managers who told us this would be removed and replaced. Staff did not ensure that blood glucose monitoring machines were consistently calibrated in line with the manufacturer’s recommendations. Calibrations had not been carried out as often as recommended on all 3 wards.

On Meadow and Highfield units, the provider had an automated system in place to monitor fridge temperatures. This helped ensure that medicines were being stored at a safe temperature. However, staff were not always checking the temperature in the clinic rooms. On Highfield unit there were several dates in September, October and November 2025 where staff had not checked the temperature.

Quality Statement Score: 2

We scored the service as 2. The evidence showed some shortfalls. The service made sure there were enough qualified, skilled and experienced staff. However, there were gaps in mandatory training compliance.

Staff vacancies varied across the 3 wards, with Marlborough House having very few vacancies and Meadow and Highfield units having higher vacancies. Highfield unit had vacancies for 27% of healthcare assistants, 66% of nurse associates and 7% of staff nurses. Meadow unit had vacancies for 55% healthcare assistants, 56% staff nurses and 20% charge nurses. All vacant posts had been advertised and managers had also been attending recruitment days. Admissions to Meadow unit were capped at 6 patients while recruitment was taking place.

Average staff turnover rates in the 12 months prior to the inspection were 20% on Meadow unit, 23% on Highfield unit and 6% at Marlborough House. Sickness rates on all wards in the 3 months prior to the inspection were between 3-5%. This was in line with the provider’s average sickness levels across the organisation.

Managers had calculated the number and grade of nurses and healthcare assistants required and adjusted these as needed. For example, managers on Meadow unit had recently changed the staffing to have an equal number of qualified and non-qualified staff on each shift, rather than having more qualified staff. Managers at Marlborough House had submitted a proposal to increase core staffing, based on the number of incident reports, with the goal of reducing reliance on agency staff.

The ward managers could adjust staffing levels daily to take account of case mix.

When necessary, managers deployed agency and bank nursing staff to maintain safe staffing levels. When agency and bank nursing staff were used, those staff received an induction and were familiar with the ward. Managers told us that the Trust planned to stop using agency staff the week following the inspection. From then they would only be using bank staff. These staff received training and supervision alongside regular staff.

There had been occasions where shifts had been unfilled. In the 3 months prior to the inspection there had been 34 instances of this on Highfield unit, 29 at Marlborough House and 24 on Meadow unit.

Staff shortages sometimes resulted in staff cancelling escorted leave or ward activities. Managers told us that staff shortages sometimes led to young people being unable to access activities requiring increased numbers of staffing, such as garden access or grounds leave. They told us that this had less impact during the week due to senior staff and members of the multidisciplinary team being present.

Staffing levels did not always allow patients to have regular one-to-one time with their named nurse. All young people were assigned a named nurse and healthcare assistant. However, staff told us that due to the high acuity on the ward and the high level of observations required to keep young people safe, they did not always have the time needed to spend with young people and complete their care plans.

There were enough staff to carry out physical interventions (for example, observations, restraint and seclusion). However, young people on all wards told us that staff were often distracted or asleep while carrying out observations. Managers told us that they had a zero tolerance policy for staff sleeping on shift and that any staff member identified to be doing this would be subject to disciplinary action.

There was adequate medical cover for both day and night and a doctor could attend the ward quickly in an emergency. Young people told us they had no problems accessing doctors when needed.

Staff had received and were up to date with most of their mandatory training courses. However, compliance with immediate life support training (ILS) was low across all 3 wards – only 47% of staff on Meadow and Highfield units and 50% of staff at Marlborough House were up to date with this. Compliance with moving and handling patients training was also low, with 56% of staff on Meadow unit, 69% of staff on Highfield unit and 64% of staff at Marlborough House being up to date with this.

Quality Statement Score: 3

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 most items of equipment well and kept them clean. Any ‘clean’ stickers were visible and in date.

At Marlborough House staff displayed a board in the corridor which had visual aids of how to wash your hands and information about infection control.However, staff did not always adhere to infection control procedures. For example, on Highfield unit we observed a member of staff serving food for a young person with a neutral-coloured plaster on their finger.

Quality Statement Score: 2

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning.

Staff did not always follow good practice in medicines management. We found 4 instances during our inspection where young people detained under the Mental Health Act (MHA) had been administered medication without the appropriate treatment authorisation in place. Staff on Meadow unit did not keep complete and up to date treatment authorisation paperwork in the clinic room and did not demonstrate an understanding of the importance of checking that the medicines they were administering were covered by the paperwork prior to administering them to young people.

Staff did not always review the effects of medicines on young peoples’ physical health regularly and in line with NICE guidance. Staff did not always monitor a young person’s physical health after they had been administered rapid tranquilisation, nor was it documented in care records that they had declined to have this done. This meant there was a risk that a decline in the young person’s physical health may not have been detected and appropriately escalated. However, no young people were prescribed high dose antipsychotic medicines.

Staff did not ensure that expired medicines were removed and appropriately disposed of. We found expired medicines on Meadow and Highfield units and expired equipment such as specimen bottles and dressings on Meadow unit. These were removed by staff during the inspection.

Staff ensured that any allergies were recorded.

Young people told us that they had opportunities to discuss and review their medicines in ward rounds.

Staff received training in medicines management and over 90% of staff were compliant with this.