Oxford trust children’s mental health ‘requires improvement’

The Care Quality Commission (CQC) inspected the inpatient child and adolescent mental health wards at Oxford Health NHS Foundation Trust in November 2025.

All three of the wards, The Meadow and Highfield units at Warneford Hospital in Oxford and Marlborough House in Swindon received an unannounced inspection from the commission following ‘information of concern it had received’.

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Warneford Hospital in Headington (Image: Damian Halliwell)

Inspectors found the service was in breach of four regulations relating to person-centred care, safe care and treatment, safeguarding and safe management of the service.

Following the inspection, CQC has changed the ratings for safe, responsive and well-led from good to requires improvement.

The ratings for caring and effective were rated good again. 

Serena Coleman, CQC deputy director of mental health in the south, said: “When we visited these CAMHS (child and adolescent mental health services) wards, we found a service where management hadn’t kept a firm enough oversight on some issues and young people in their care were feeling the impact of that.

“All of the young people we spoke with said they didn’t feel involved in decisions about their own care.

“Half of the care plans we reviewed were generic and didn’t reflect individual needs or wishes.

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“We had serious concerns about how restraint was being used. Records didn’t always show that staff had tried other approaches first, and two young people reported negative experiences during restraint.

“Blanket restrictions were also in place across all three wards meaning every young person was subject to rules around accessing snacks, drinks and outdoor space, regardless of their individual circumstances or risk level.

“These are the kinds of restrictions that should only be applied to individuals, and when there’s a clear reason to do so.”

The Care Quality Commission inspected the wards (Image: Alamy/PA)

Inspectors found the service had given medication to four young people detained under the Mental Health Act without the correct treatment authorisation in place, and staff did not regularly remind young people detained under the act of their rights.

It was found that eight young people across two wards hadn’t had their rights repeated to them since admission, one of them for six months.

Ms Coleman added: “What makes these findings more concerning is that the trust’s own internal processes hadn’t identified many of them, risking that these concerns will go unaddressed.”

Despite the need for improvement, inspectors did find positives at the trust.

Ms Coleman said: “We also found staff worked well together across different disciplines, and we observed many warm and respectful interactions between staff and young people throughout our visit.

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“Carers spoke positively about the service, and the support available for young people’s physical wellbeing including gym access, yoga, and weekly wellbeing clinics was good.

“At Marlborough House, staff had developed an innovative nature-based therapy programme in collaboration with a local wildlife trust.

“The trust knows where it needs to improve and we will monitor them to make sure young people are safe while this happens.”