CQC welcomes improvements at Oxleas NHS Foundation Trust

The trust provides wards for older people with mental health problems across four locations: Shepherdleas Ward at Oxleas House and Oaktree Lodge at Memorial Hospital, both in Greenwich, Scadbury Ward at Green Parks House in Bromley and Holbrook Ward at the Woodlands Unit in Bexley.

CQC carried out an unannounced focused inspection in April to determine whether the trust had complied with a warning notice issued due to concerns about the assessment and management of ligature risks to patients, and a failure to implement key safety recommendations following a serious incident investigation.

CQC previously carried out an unannounced focused inspection of all four wards in October 2020, following the unexpected deaths of two patients, one on Scadbury Ward in February 2020 and one on Shepherdleas Ward in May 2019. Both patients died as a result of fixing ligatures to fittings in the wards. Following this inspection, while the overall rating for the trust remained good, the rating for the service went down to inadequate overall, and it was also rated inadequate in the safe and well-led domains.

In April, CQC visited all four wards for older people with mental health problems to look at the safe and well-led domains in full again. The ratings for safe and well-led have now improved to good, and inspectors found that the trust had complied with the warning notice.

Jane Ray, CQC’s head of hospital inspection for mental health, said:

“I am pleased to report that we found significant improvements at Oxleas NHS Foundation Trust during our recent inspection. The trust had complied with the warning notice and refurbishment work was underway across all four wards to remove any ligature risks. Patients will be much safer when this work is carried out. It is due to be completed by the end of July.

“The overall governance of the service has also improved, including the introduction of a matron with responsibility for reviewing ligature risks on the wards and overseeing the delivery of improvements.

“We also found that all the wards were safe, clean, well-equipped and fit for purpose with risks to patients well-managed. The wards had enough doctors, nurses and therapists with the right training to keep people safe by de-escalating and managing distressed behaviour, using minimally restrictive practices.

“Overall, this is a very positive report. Managers and staff have worked hard to address the concerns we had during our previous inspection and ensure that improvements are made.”