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St Andrew's Healthcare - Mens Service Requires improvement

We are carrying out a review of quality at St Andrew's Healthcare - Mens Service. We will publish a report when our review is complete. Find out more about our inspection reports.

Details of this locations CQC registration


Here you will find the list of services and areas where we, the Care Quality Commission, authorise and regulate this service to operate. If you think this service is operating services not listed here please contact us

Type of service
  • Hospitals - Mental health/capacity
Specialisms/services
  • Caring for adults over 65 yrs
  • Caring for adults under 65 yrs
  • Caring for people whose rights are restricted under the Mental Health Act
  • Learning disabilities
  • Mental health conditions
Local authority
  • West Northamptonshire

Regulated services/activities

CQC register St Andrew's Healthcare - Mens Service to carry out the following legally regulated services here:

Treatment of disease, disorder or injury

  • Mrs Katie Fisher is responsible for these services.
  • Mr Alastair Benjamin Clegg is the registered manager for these services at this location.
Condition of this registration relating to carrying out this regulated activity

1. The Registered Provider must not admit any new service users to the wards listed below without the written permission of the Care Quality Commission.

• Meadow

• Marsh

• Fern

• Hawkins

• Sunley

• Acorn

• Spencer North

• Spencer South

• Berkeley Lodge

2. The Registered Provider must ensure that the wards listed in paragraph 1 are staffed with the optimum numbers of suitably skilled staff, as assessed by the Registered Provider to meet service users’ needs and to undertake service users’ observations as prescribed.

a. By 17:00 on Friday 30 July 2021 the Registered Provider must undertake a review of section 17 leave, including prescribed levels vs. hours taken. The review must include all instances where leave was not taken, or the prescribed amount had not been taken and provide reasons for this. By 17:00 on Tuesday 3 August 2021 the Registered Provider must report back to the Commission on this review. This should include all wards listed in paragraph 1.

b. Commencing from Friday 16 July 2021 and thereafter on a fortnightly basis, the Registered Provider must provide the Commission with details for the previous two weeks as to when staff numbers have not been optimum, the reasons for this and the steps they took to mitigate risks arising from this. This should include all wards listed in paragraph 1.

3.

a. By 17:00 on Friday 23 July 2021 the Registered Provider must undertake a review of all service users’ observation records on the wards listed in paragraph 1 considering their needs and individual circumstances. The review should consider whether service users’ observation levels need to remain the same, be increased or be reduced considering their needs and risk levels throughout the day. By 17:00 on Tuesday 28 July 2021, the Registered Provider must report back to the Commission on this review.

b. The Registered Provider must ensure individual service users observation levels are reviewed as and when their individual circumstances require, and no less than once per month. This should include all wards listed in paragraph 1.

c. Commencing from 23 July 2021, the Registered Provider must ensure that service users are observed in accordance with the review undertaken under (a) and any subsequent reviews undertaken. This should include all wards listed in paragraph 1.

4

a. The Registered Provider must ensure that staff undertaking observations on the wards listed in paragraph 1 do so in line with the provider’s engagement and observation policy and protocol and the reviews carried out under 3(a) and any subsequent reviews.

b. Commencing from 09:00 on Friday 30 August 2021 and on a fortnightly basis, the Registered Provider must carry out audits on observations and report to the Commission on these audits within 3 working days of the audits taking place. This should include all wards listed in paragraph 1.

5.

a. By 23 July 2021, the Registered provider must implement an effective system to ensure that all incidents are recorded accurately and in a timely way to assess the risk to the health and safety of service users and to do all that is reasonably practicable to mitigate such risks. By Tuesday 28 July 2021, the Registered Provider should report to the Commission on the system put in place.

b. By 17:00 on Friday 6 August 2021 the Registered Provider must undertake a review of all service users’ progress notes on the wards listed in paragraph 1 from 8 July 2021 up to 14 July 2021 to ensure all issues identified as incidents have been recorded correctly. The review should ensure that the information in the recorded incident matches that recorded in the progress notes and that the incident was reported in a timely way. The Registered Provider should ensure there are no delays to the associated investigations. By 17:00 on Tuesday 11 August 2021, the Registered Provider must report back to the Commission on this review

c. By 17:00 on Friday 13 August 2021 the Registered Provider should review staff skills and competencies and identify whether special training is required for Meadow, Marsh, Fern, Hawkins, Sunley and Acorn wards, including training on closed cultures. By 17:00 on Tuesday 17 August 2021 the Registered Provider must report back to the Commission on this review. The Registered Provider must ensure any identified training is completed by Friday 24 September 2021.

d. Commencing from Friday 30 July 2021 and thereafter on a fortnightly basis, the provider should ensure audits are carried out to ensure incidents are being recorded and match what is contained in progress notes and report to the Commission on these audits within 3 working days of the audits taking place. This should include all wards listed in paragraph 1.

Assessment or medical treatment for persons detained under the 1983 Act

  • Mrs Katie Fisher is responsible for these services.
  • Mr Alastair Benjamin Clegg is the registered manager for these services at this location.
Condition of this registration relating to carrying out this regulated activity

1. The Registered Provider must not admit any new service users to the wards listed below without the written permission of the Care Quality Commission.

• Meadow

• Marsh

• Fern

• Hawkins

• Sunley

• Acorn

• Spencer North

• Spencer South

• Berkeley Lodge

2. The Registered Provider must ensure that the wards listed in paragraph 1 are staffed with the optimum numbers of suitably skilled staff, as assessed by the Registered Provider to meet service users’ needs and to undertake service users’ observations as prescribed.

a. By 17:00 on Friday 30 July 2021 the Registered Provider must undertake a review of section 17 leave, including prescribed levels vs. hours taken. The review must include all instances where leave was not taken, or the prescribed amount had not been taken and provide reasons for this. By 17:00 on Tuesday 3 August 2021 the Registered Provider must report back to the Commission on this review. This should include all wards listed in paragraph 1.

b. Commencing from Friday 16 July 2021 and thereafter on a fortnightly basis, the Registered Provider must provide the Commission with details for the previous two weeks as to when staff numbers have not been optimum, the reasons for this and the steps they took to mitigate risks arising from this. This should include all wards listed in paragraph 1.

3.

a. By 17:00 on Friday 23 July 2021 the Registered Provider must undertake a review of all service users’ observation records on the wards listed in paragraph 1 considering their needs and individual circumstances. The review should consider whether service users’ observation levels need to remain the same, be increased or be reduced considering their needs and risk levels throughout the day. By 17:00 on Tuesday 28 July 2021, the Registered Provider must report back to the Commission on this review.

b. The Registered Provider must ensure individual service users observation levels are reviewed as and when their individual circumstances require, and no less than once per month. This should include all wards listed in paragraph 1.

c. Commencing from 23 July 2021, the Registered Provider must ensure that service users are observed in accordance with the review undertaken under (a) and any subsequent reviews undertaken. This should include all wards listed in paragraph 1.

4.

a. The Registered Provider must ensure that staff undertaking observations on the wards listed in paragraph 1 do so in line with the provider’s engagement and observation policy and protocol and the reviews carried out under 3(a) and any subsequent reviews.

b. Commencing from 09:00 on Friday 30 August 2021 and on a fortnightly basis, the Registered Provider must carry out audits on observations and report to the Commission on these audits within 3 working days of the audits taking place. This should include all wards listed in paragraph 1.

5.

a. By 23 July 2021, the Registered provider must implement an effective system to ensure that all incidents are recorded accurately and in a timely way to assess the risk to the health and safety of service users and to do all that is reasonably practicable to mitigate such risks. By Tuesday 28 July 2021, the Registered Provider should report to the Commission on the system put in place.

b. By 17:00 on Friday 6 August 2021 the Registered Provider must undertake a review of all service users’ progress notes on the wards listed in paragraph 1 from 8 July 2021 up to 14 July 2021 to ensure all issues identified as incidents have been recorded correctly. The review should ensure that the information in the recorded incident matches that recorded in the progress notes and that the incident was reported in a timely way. The Registered Provider should ensure there are no delays to the associated investigations. By 17:00 on Tuesday 11 August 2021, the Registered Provider must report back to the Commission on this review

c. By 17:00 on Friday 13 August 2021 the Registered Provider should review staff skills and competencies and identify whether special training is required for Meadow, Marsh, Fern, Hawkins, Sunley and Acorn wards, including training on closed cultures. By 17:00 on Tuesday 17 August 2021 the Registered Provider must report back to the Commission on this review. The Registered Provider must ensure any identified training is completed by Friday 24 September 2021.

d. Commencing from Friday 30 July 2021 and thereafter on a fortnightly basis, the provider should ensure audits are carried out to ensure incidents are being recorded and match what is contained in progress notes and report to the Commission on these audits within 3 working days of the audits taking place. This should include all wards listed in paragraph 1.