Oxford Health NHS Foundation Trust

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• 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 means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question Good. At this assessment the rating has remained Good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff members reported feeling that the trust's culture had improved. There had been significant work carried out with the team on Kestral Wards to ensure the teams collaborated effectively, which was driving significant improvements on the wards. Night shift working practices had improved, alongside the reduction of agency staff. The nursing team reported positive collaboration with the medical team and felt they were recognized as clinically essential.

Across the services staff highlighted effective multidisciplinary team working, with handover and liaison processes on the wards. However, some staff expressed concerns about a lack of forensic and mental health expertise due to the introduction of new staff and managers. When we reviewed trust security and risk management training data we could see that on average these were lower than other mandatory trainings, however the trust had a plan on how to improve this across the improvement plans for the wards and this did not appear to have an impact on safeguarding of patients.

Ward managers and one staff member suggested that further improvements were needed within the clinical teams, such as streamlining processes and positioning ward managers closer to the wards.

Staff said they felt well supported by senior leaders and that they were visible on the wards. Staff said they felt well supported by their immediate ward managers, however some staff and ward managers said they would prefer to be based on the wards rather than based in group offices in the administration areas. The staff on Evenlode recognised having a full time Matron allocated to the ward was beneficial and they felt that it made the ward to board connection more effective. On Kennet ward the Senior leadership team recognised that there was ongoing work required continue to improve the culture but improvement was being shared through the governance clinical effectiveness meetings.

We saw evidence of leadership competency, support and development. Senior leaders said that staff in management roles had received training on quality improvement methodology and that they were delivering away days for staff to improve visibility to the workforce . All members of the senior leadership team were clinicians and had experience of working in secure services. There was safe recruitment of leaders in relation to fit and proper person requirements. There were structures in place for reporting and evidence of succession planning.

A Freedom to Speak Up Guardian regularly visited the wards and ward managers and staff said they were aware of the process for raising concerns. The freedom to speak up guardian provided an annual report to the trust to create an open and transparent culture of improvement and learning where raising concerns was welcomed. Senior leaders said the wards had a more open culture now, with staff feeling safe to speak out. However, three members of staff said they were apprehensive to raise concerns and were not confident that action would always be taken in response to concerns raised. Other staff told us that there had been some isolated complaints made alleging bullying and discrimination.

There was a whistleblowing policy in place and staff knew where to find this and how to use it . The Freedom to Speak up Guardian regularly visited the ward and staff could contact them if they had concerns to discuss. There was a freedom to speak up report and improvement plan which was routinely reviewed and updated at the trust board meetings. All actions on the improvement plan had been completed in March 2024. A freedom to speak up network had been developed and there were 28 trained freedom to speak up champions as part of this. However some staff did not feel that their concerns would be listened to or acted upon despite processes being in place.

There had been some cultural improvements made as part of the workforce improvement plans and there was additional support for black and minority ethnic staff. Additionally, there was a wellbeing lead and equality and diversity champions.

As part of the mandatory training, staff received equality, diversity and human rights training. Compliance was at 98% at the time of inspection. There was an equality and diversity sub-group who supported staff, for example, with experiences of racism from patients.

Managers put reasonable adjustments in place for staff members to help them carry out their role. For example there were staff who had shift timings changed to enable them to meet their caring responsibilities.

The trust had undertaken equality monitoring of staff within the service to ensure it is diverse in its make-up and representative of the patient group. As a result of this the trust had developed a quality improvement project to improve race equality in the Forensic Services.

Staff said that the electronic record keeping system, supported them in their role and that there were systems in place to manage fire safety and ligature risks on the wards. However ligature information was not always easily accessed by ward staff. Ward managers and the pharmacist we spoke with outlined the systems in place on their wards to ensure effective governance in relation to medicines management.

Senior leaders said that there were processes in place to ensure better oversight of incidents, complaints and concerns. Staff were engaged in the roll out of the PSIRF incident management framework. Ward managers showed us the system they had for monitoring mandatory training updates. We could see the Key performance indicator framework the service used which generated a Quality Dashboard which supported the ward managers to see at a glance what areas their ward was excelling in and which areas needed additional input.

The senior leadership team and the ward managers met to review incidents, complaints and concerns and identify themes. Lessons learned were cascaded to staff via staff meetings and team bulletins. There was evidence of consistent governance relating to ligature, fire and security risks.

Patients that we spoke with said that they were able to maintain links with services in the community such as community forensic teams and their care management teams when supported by the ward staff. Patients and staff could meet with members of the provider’s senior leadership team and commissioners to give feedback.

Senior leaders regularly engaged with external stakeholders, such as commissioners and Healthwatch.

The advocates attended the ward and were invited to patient meetings and the senior leadership team meetings. Advocacy information was widely available on the wards and advocates were provided with confidential spaces to meet with people.

Community meetings took place regularly on each ward. Advocates regularly attended the ward and senior leaders and ward staff were supportive of the service.

Ward managers and staff described effective systems for reporting and investigating incidents to ensure debriefs were offered to staff, feedback was shared and safety improvements were made in response to lessons learned.

Staff gave us examples of an improvement made due to lessons learned following an incident which included improvements to record keeping in relation to handover documentation. Another staff member described how improvement had worked for them as a result of the TRiM initiative (Trauma Risk Management), which is a process to support people following traumatic incidents. Senior leaders told us that over 50% of staff had taken up the opportunity to be supported by the TRiM project. There was evidence of staff engagement with quality improvement projects on the wards, they knew how to apply quality improvement methodologies and the aim was to embed learning culture on the wards. Senior leaders told us of the quality improvement (QI) Hub, which met virtually to progress and discuss 23 ongoing QI projects and was open to all staff.

Ward managers received safety alerts with information about lessons learned from incidents elsewhere in the trust.

Managers had visited other forensic services to gather insights and collaborated with an external team as part of the quality network. Improvement initiatives were co-produced with input from clinical staff, ward staff, and patients, embedding a ward-to-board governance structure. Cultural improvements included visible senior leadership and role modelling, with staff and patients being familiar with the senior leadership team. Evidence of a learning culture was seen through initiatives like the patient safety panel and lessons learned from safeguarding referrals.

Senior managers told us about the patient engagement lead role which was focussed on engagement with staff at all levels after action reviews. There was also a piece of work to involve staff in incident simulations as some new staff had never encountered aggression. Some ward managers were not engaged with or aware of the drivers for improvement at the trust, for example previous CQC findings or the recommendations from external reviews.