Oxford Health NHS Foundation Trust

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

At our last assessment in 2019 we rated this key question as Good This meant that the service was considered to be overall safe and there were assurances about safety.

At this assessment the rating has remained as Good. We assessed six quality statements. Staff were providing safe care and treatment but the environment in some of the long term segregation areas was not always safe. There was a positive learning safety culture where events were investigated, and learning was embedded to promote good practice.

This service scored 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We spoke with 30 patients across the seven wards visited during the assessment. Patients told us that they were aware of the complaints procedure and how to use it.

Community meetings took place regularly and improvements were made because of patient feedback. When speaking with people using the service, 24 out of 30 patients we spoke with told us that they felt safe on the wards.

Levels of restrictive interventions were reported by patients to be low and reducing. Data supplied by the trust showed that the average use of physical restraint was reducing month by month and the use of rapid tranquilisation to manage severe behaviour was low. Rapid tranquillisation is the use of medication, usually by injection to quickly calm a person who is extremely distressed and at risk of harm, when other methods haven't worked. Patients told us that staff avoided using restraint by using de-escalation techniques and restrained patients only when these failed and when necessary to keep the patient or others safe.

Patients felt that staff were interested in their care but did not routinely explain what their care plans meant to them. Half the patients on Kennet Ward stated that they had not seen their care plan but when we reviewed the care notes on the ward, we could see that all the sets of care plans we reviewed showed evidence of patient involvement. This suggests there may be an issue with the way the care plans were shared with the patient group. Information provided by the trust informed us that a new care plan template had just gone live, prior to this the trust were unable to print care plans, this has now been resolved and patients are given a printed copy.

The wards participated in the provider’s restrictive interventions reduction programme, which met best practice standards, however the audits of restrictive practices were being managed at senior management level and not local level. This meant that some wards such as Woodlands Ward had local blanket restrictions in place. These were not being recorded on the restrictive practice audit and overseen by the senior managers.

People felt supported to raise concerns and felt staff treated them with compassion and understanding.

Staff received feedback from investigation of incidents, both internal and external to the service. Staff met to discuss that feedback.

Staff were debriefed and received support after a serious incident. We observed this happening immediately following an incident on Kennet ward and all staff involved were supported to be taken off the ward to discuss the incident and how it had developed and what could have been done differently. This appeared to be a constructive process and staff felt supported.

Managers encouraged staff to raise concerns when things went wrong. During staff meetings, the whole team discussed and learnt from clinical issues. Staff felt there was an open culture, and that safety was a priority.

We found examples of how learning was shared following investigations into safety events. The provider also shared learning across the wider organisation and we saw examples where staff received safety and learning bulletins from other areas within the organisation.

The service’s referral and admission processes ensured that staff had access to essential information about the patient to determine if the patient’s needs could safely be met. We reviewed the preadmission information for 36 patients and there was evidence that preadmission information was recorded clearly.

Although most clinical notes were stored electronically, the wards used a combination of electronic and paper records to record daily observations, community access forms and physical healthcare monitoring. Staff made sure they were up-to-date and complete.

Multidisciplinary team meetings and clinical governance meetings took place regularly at senior management and ward level to review the quality of the service, risks in the service and the service’s transformation and improvement plans; however ward based staff meetings were not always held regularly.

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.

Records were stored securely on the wards and remained in the office or the clinic room.

The provider monitored people who were admitted to their services out of area and there was a policy and pathway for people to return home.

The senior management was part of the provider collaborative which meant they were working with local forensic and secure services to review and strengthen the pathways between services.

Partners told us that ward rounds, care review meetings and discharge meetings were routinely held for patients. The provider invited external partners to these meetings and worked in partnership with external organisations in order to support and facilitate safe transitions to and from the service.

Of the 30 patients we spoke with, 24 patients said that they felt safe on the ward and 20 patients said that staff spoke to them with kindness dignity and respect. However, six patients had some concerns including two patients who said that they did not feel safe on the ward, two patients said that specific staff did things to deliberately provoke them and two patients said staff did not respect their privacy. This meant that the service did not always protect some people’s right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

We spoke with a number of leaders who told us that there was an improved culture regarding safeguarding reporting and better relationships with local safeguarding structures. The service had lots of Ward managers and staff described appropriate processes for dealing with safeguarding concerns. They also described the measures in place to support patients' protected characteristics on the ward. In October 2024 the forensic services reported 18 safeguarding concerns of which 14 progressed into safeguarding alerts however none were followed up by the local authority which means that they were satisfied with the way the service had investigated and managed the concerns.

Staff routinely identified and raised safeguarding issues. Staff knew their patients, were aware of their protected characteristics and cared for them in line with this.

There was a safeguarding policy in place and staff knew how to access this to make appropriate referrals to the local safeguarding authority. Across the forensic services training compliance for safeguarding vulnerable adults level 2 and 3 averaged at 100% Safeguarding children levels 2 and 3 averaged at 95%. The freedom to speak up guardians routinely visited the ward which ensured that staff were able to speak out about any concerning practice they identified.

Staff described how the risks relating to each patient's care were assessed on admission to the service using a nationally recognised assessment tool and regularly reviewed, including following any relevant incident. Staff told us that there were low levels of physical intervention on their wards and rarely used. Rapid tranquillisation is the use of medication, usually by injection, to quickly calm a person who is extremely distressed and at risk of harm, when other methods haven't worked. The rapid tranquilisation audit for Kestral ward showed that only one patient had received rapid tranquilisation in the last six months and documentation of the administration of rapid tranquilisation was good with clear notes stating what was given and reason for administration.

Staff used restraint as a last resort and only after all efforts at verbal de-escalation had failed. The provider had a reducing restrictive practice program that patients were involved in and had introduced a patient safety panel with two patient safety partners with lived experience of using Oxford services. This meant that people who used services were directly involved in oversight of patient safety issues.

However we did not see sufficient evidence to demonstrate that blanket restrictions were only imposed where necessary to meet the needs of the patients and maintain the safety of patients and staff or that they were being kept under regular review when imposed. The trust had been managing blanket restrictions at senior management level and were not being managed at local level. Not all wards were able to provide a copy of their blanket restrictions register and, where this was available, there was no evidence to show the blanket restrictions were being regularly reviewed and removed where no longer required. We also identified blanket restrictions, for example relating to access to cups and caffeinated drinks, which were not documented on the relevant ward’s register.

We observed staff interactions with patients on each ward and saw that the majority were positive. We saw some patient centred care plans showing patient and carer involvement.

The trust used the nationally recognised tool the HCR-20 (historical clinical risk management- 20) to manage risk. Risk assessments were completed on admission and reviewed regularly and after each incident.

Staff followed best practice in using restraint only as a last resort after all other interventions had been unsuccessful. There had been 95 episodes of restraint and 35 episodes of seclusion across the wards in the three months prior to the inspection. This appears to be lower compared to similar sized services across the country.

Therapeutic observation of patients was used appropriately as a method of managing risk.

All patients said their wards were fairly clean. A patient on Kennet ward said their ward was always clean and they helped the staff to clean it. There was adequate space on the ward and patients were happy with the visitor’s rooms. A patient on Evenlode ward said there was an interactive touch floor projector in the sensory room, which they used when they felt overstimulated. The wards had a range of rooms available to patients including activities rooms, quiet lounges and interview rooms. However, on Woodlands House the therapy area did not offer privacy and dignity to patients attending psychological treatment groups. In addition on every ward patients complained that the garden areas were poorly maintained and they did not have adequate access to outside space.

The seclusion and long term segregation areas on Kennet and Kestral Wards met the basic guidance of the code of practice but there was impact on the patients who were not in seclusion or long term segregation and were living in those areas. The patient’s privacy and dignity was compromised by the location of the seclusions rooms which led directly from the ward corridors. We saw that the trust had made significant updates to the seclusion area on Evenlode and they had plans to redesign these areas. However there were no agreed time periods when this would be done and this was something that was highlighted in the 2019 report as an action that the trust should take to improve.

On all wards there were clear ‘You Said, We Did’ boards that patients later corroborated were being used in the patient meetings. Patients reported individualised care and the opportunities to integrate their interests into their care plans.

We spoke with five ward managers and 26 other members of staff. Staff were able to describe a range of security procedures on each ward including regular checks and counts of potentially hazardous items and environmental checks.

There was an allocated support worker dedicated to ward security on each ward every shift. However staff also told us that there were mistakes and omissions with security checks and this was not always addressed. For example, we observed this on Evenlode Ward where a razor had been removed and used and not accounted for on the security checklist. This meant that although systems were in place, the security and safety of patients was not always prioritised and this created risks to patient and staff safety.

There were ligature audits in place for all wards. However ligature risk assessments were not always easy to access by the staff and not all staff could not articulate what the environmental risks were, and how they were working to mitigate these risks. This also meant that there was a risk that new agency or bank staff who were not familiar with the ward environment would not be shown how to successfully manage the environmental risks. We reviewed information provided to us by the trust that showed how agency staff and new staff were shown how to safely consider risks relating to ligatures when they first started working on the wards.

Staff told us that the observation policy was followed. Staff told us they rotated patient nursing observations within the staff team hourly and they were able to take a break between one to one observations with patients. Staff had received competency based training in the therapeutic observation of patients and there were enough staff on the wards to safely manage this.

Wards were accessible for patients with mobility needs and disabled bathrooms were available on the wards.

Patients gave mostly positive views about the staff that were caring for them. Of the 30 patients were spoke with, 17 patients spoke positively about the staff on their wards, saying that they treated them with kindness and were caring and respectful. Nine patients said that staffing levels on the wards were good. However, five patients said that leave and activities were sometimes cancelled due to staffing levels. Seven patients said they felt sometimes staff were just standing around and waiting for something to happen rather than engaging to reduce the agitation of the patients. This was observed on two of the wards, staff were positioned in communal areas of the ward, however staff were seen to be interacting positively with patients.

Staff and leaders gave positive views on safe and effective staffing. Staff told us that they received the right support from their managers to deliver safe care. Staff received regular supervision and an appraisal and there was an induction for new staff. Staff felt that the senior leaders of the forensic service and the consultants were very visible on the wards and felt that they offered support to manage challenging behaviour or complex needs when required. Staff members said team meetings took place regularly, although we saw that staff meetings were not as frequent as planned. Managers described a full and thorough handover process between shifts which covered observation levels, patients’ mental state and presentation, safeguarding and physical health for each patient and the skill mix of the team. The ward manager could adjust staffing levels daily to take account of case mix. There were enough staff to carry out physical interventions (for example, observations, restraint and seclusion) safely (and staff had been trained to do so). At least one qualified nurse was present in communal areas of the ward at all times.

We saw that staffing levels across the wards were good. During the inspection there were staff in communal areas and one to one sessions between patients and their named nurses routinely took place. Most staff that we spoke with were qualified and experienced. We saw that staff responded promptly to assistance alarms when required.

The provider had processes in place to ensure safe staffing. Permanent staffing levels for each ward were between six and twenty registered nurses and seven and 21 HCA’s. On top of this each ward had nurse associates and administration staff. Each ward was supported by a multidisciplinary team which included a psychiatrist, occupational therapist, psychologist and the patient’s named nurse. Each ward had a leadership team consisting of a ward manager, duty manager and matron. Staff used a proforma during the daily safety huddle to consider safe staffing numbers and ensure that inductions for temporary staff took place. In October 2024, the Services reported a total of 279 incidents, a decrease on the previous reporting period of approximately 2%.

There was a local induction and assurance pack for observations for new starters; staff did not deliver observations of patients until sign off of their competency level by senior staff.

The mandatory training courses in place for staff were appropriate and thorough. Staff were compliant in most courses and the overall mandatory and statutory training compliance was 95.21% which was just over the trust target of 95%.

Staff received regular supervision and appraisal in line with trust policy. Supervision compliance was at 88% at the time of the assessment and appraisal compliance was at 86% at the time of the assessment. In addition the trust runs a Personal Development Review season that runs from April – July. During this time all staff have their appraisals completed.

Patients told us that the wards were clean, tidy and well maintained. One patient told us that the wards were kept clean and they were regularly supporting the staff voluntarily to keep the communal areas clean and to support the staff.

Staff and leaders told us that there we an infection prevention and control policy in place which covered all areas including hand hygiene, personal protective equipment, safe management of equipment and safe disposal of waste.

The provider had a dress code for staff which included being bare below the elbow and with the absence of jewellery or false nails. During our inspection we found that not all staff adhered to this dress code. On all the wards we visited we observed inconsistent compliance with the Trust ‘bare below the elbows’ dress policy and we observed staff with jewellery, watches and false nails.

There were a number of processes in place to prevent the spread of infection. This included cleaning schedules and audits. Hand hygiene facilities were readily available including hand sanitizers and wash stations, and staff demonstrated good hand hygiene practices. Staff were up to date with infection control training with an average of 94% of staff had completed infection prevention and control training in the month of the inspection.

People were appropriately involved in decisions about their medicines. Patients were provided with information about their medicines in a format they could understand, and their preferences and concerns were taken into account. Almost half of the 30 patients we spoke with said they were given enough information about their medicines. Wards demonstrated a commitment to safe and effective medicines optimisation. Patients’ responses to medicines were monitored regularly, and any adverse effects were reported and managed promptly. The wards had robust systems in place to ensure that medicines were prescribed, administered, and managed in line with best practice guidelines and legal requirements.

The wards had a designated medicines management lead who oversaw medicines optimisation and ensured compliance with relevant policies and guidelines. Regular audits were conducted to monitor medicines management practices, and findings were reported to the senior management team. There was a clear medicines policy that was reviewed and updated in line with national guidance.

Medicines were prescribed by qualified and competent practitioners, and prescriptions were reviewed regularly by the multidisciplinary team. There were clear protocols for the administration of medicines, including high-risk medications such as high dose antipsychotics and controlled drugs. Staff followed appropriate procedures for checking patient identities and obtaining consent before administering medicines. Medicines were stored securely in accordance with legal requirements, and controlled drugs were managed in line with national guidelines. There were clear procedures for the disposal of unused or expired medicines.