St Andrews Healthcare Northampton

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

We identified some areas of concern under the safe key question which will require an action plan. The provider has a system and process for learning, however learning had not always taken place. We found that patients and staff did not always feel safe on the wards. Some patients told us that they had been subject to verbal and physical aggression, including racism from other patients. We were told that not all staff had protected patients from abuse and that there were concerns about a closed culture specifically on 1 ward, which the provider had identified and had improvement plans in place to address. Patients told us they had not been involved in their care planning or risk assessment process. We found evidence of blanket restrictions relating to access to hot and cold drinks and snacks. Patients told us that they had experienced several issues relating to maintenance, including no access to hot water and delays repairing the washing machine and tumble drier. We found that not all ward areas were well maintained or clean. We found evidence of staining of a dried brown substance on a patient’s bedroom floor, walls and bed. Patients and staff at all levels spoke to us about staffing being a concern. The service had a high level of vacancies together with a high use of non-permanent staff. Ward staff were not always available for patients, who told us that they had to wait for their needs to be met. Staff were experiencing ongoing issues with the electronic prescribing system (EPMA) going offline, and staff did not always follow the provider’s contingency plans.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We saw evidence of learning which had been shared with teams. Staff we spoke with described a variety of ways in which they stayed informed and looked at learning following feedback from patients and incidents.

The provider had a system and process in place for incidents and complaints to be investigated and reported. Leaders shared learning from investigations via patient safety action notes (PSAN). Examples of learning shared related to specific needs for patients whilst on enhanced observations (for example patients may need to always have their arms visible). Two other learning notices related to patients being able to access the internet via their television set and SMART phone listening capabilities. The identified risk related to patients being able to access inappropriate sites and listen into other people’s telephone calls via these devices.

Most patients who spoke to us about their transfer from other wards or providers, told us that their transfers had gone well. However, not all patients felt that their views had been listened to and considered. However, the provider shared some details of oversight, assurance and improvement processes that are in place. The provider has shared the outcome of a care plan engagement audit (undated), and care plan audit for December 2024, (which had showed a review of just 4 records).

Staff told us there was a clear process from referral through to assessment and admission. We were told that a member of the ward staff was involved in assessing referrals made for the ward and that the outcome of assessments was discussed as a multidisciplinary team. We saw staff from other specialities were regular attendees on the ward including regional commissioners.

The provider had good working relationships with the regional commissioning teams, host healthcare teams and safeguarding teams.

We saw examples of partnership working, for example with the commissioners, acute hospital, police, local authority safeguarding, and adult social services.

Systems, processes and practices to make sure people are protected from abuse and neglect had not always been effective. Nine out of 13 patients we spoke with (69%) about safeguarding, told us that they did not feel safe on the wards. Patients spoke about being bullied by co-patients; patients also told us that they had been assaulted physically or verbally (including racism) by fellow patients and staff. However, the provider has provided evidence that they had not been made aware of incidents of racism by staff. A member of the assessment team observed staff trying to silence a patient in a community meeting when they discussed bullying on the ward. The provider has reported that the staff member intervened to prevent retaliation, and the patient’s concerns were discussed with them outside the meeting. One patient referred to a co-patient stating that staff were also scared of them and that “staff also get bullied”. Nineteen allegations of abuse by staff had been made by patients during the 6-month period from June to November 2024. During the community meeting on Rose ward on 13 November 2024, patients raised concerns regarding an increase in aggressive incidents and stated that they did not feel safe on the ward.

We spoke with 27 staff members; all of whom were able to demonstrate how they would identify and raise a safeguarding issue. Staff told us that they undertook safeguarding level 2 training online and attended safeguarding level 3 training face to face. However, not all patients had been protected from harm. We were informed that an inappropriate relationship had taken place between a staff member and a patient. Both the patient and the staff member were no longer at the hospital, and appropriate actions were taken by the provider following the incident. However, we were informed that some staff knew about the relationship and took no action to raise concerns. This raised concerns about a closed culture on the ward. The provider had already recognised this closed culture through their own investigation and was in the early stages of taking appropriate actions to address this.

We saw that staff had appropriately made referrals to the local safeguarding team. Staff had raised 81 safeguarding concerns during the 6-month period from June to November 2024. Thirty-seven referrals (46%) were closed at referral stage, 40 referrals met the section 42 threshold for an enquiry with 22 enquiries being completed by the local authority (13 now closed), and 18 by the provider (9 now closed). In the same 6-month period, there were 468 episodes of physical aggression and violence on the wards, of which 214 resulted in no harm, 204 in low harm (89% of incidents), 44 in moderate harm and 6 in major harm. In addition, there were 115 episodes of verbal aggression.

The provider had a safeguarding policy in place, and the teams had identified safeguarding leads in place. All staff knew what the safeguarding process was and how to raise a safeguarding alert, including raising an incident. However, the systems and processes in place were not always operating effectively to protect patients from coming to harm.

Not all patients felt informed about their risks and how to keep themselves safe. Five out of seven (71%) patients we spoke with (across all wards) about how staff managed their risks, told us that they did not know what a risk assessment was. However, the provider has shared that over 87% of patients have attended their care programme approach meeting, where risk is discussed with the clinical team and patients. However, there is a range of other meetings and sessions with staff, where risk should be discussed with the patient. However, one patient told us that “staff take stuff away” in relation to risk, and another patient was aware and understood that they were ‘not allowed to have access to cords and phone chargers. These were a restricted item due to the potential risk of self-harm. Patients were involved in community meetings and had access to advocacy services. One patient told us that staff used access to leave as a threat. However, the provider explained the importance of detailed clinical risk assessment prior to use of any Section 17 leave to ensure the safety of both patients and staff.

Staff we spoke with said patients were nursed in the least restrictive way possible, however we observed on Prichard ward that patients did not have free access to hot and cold drinks and snacks. We were informed that access was restricted due to some patients having diabetes or had presented a risk. Staff did not appear to be aware that restrictions should be individually risk assessed. The provider shared a copy of their restrictive practice audit tool, which confirms blanket restrictions in relation to open access to hot drinks and ability to vape and smoke, which applies to all patients on Prichard ward.

We looked at 18 care records across all 4 wards and found all were comprehensive and had updated risk assessments in place. Risk assessments about care were person-centred and proportionate, however records showed limited patient involvement, or regular review with the patient. The records did not clearly indicate where and why patients had not been involved in their care planning process. However, the provider has shared results of a care plan audit which indicates that 68% of MDT care plans have either been written by patients with the MDT, or had parts added by the patient. Only 18% of care plans lack involvement of patients due to the patient being either unable or unwilling to engage in the care planning process. Most care plans were written in the third person (not from the patients’ perspective).

Patients on Pritchard ward told us that they had not had access to hot water to shower. Therefore, patients had to shower with tepid water for several days. The provider has informed us that that this had not been raised by patients prior to inspection. This was raised with the service and addressed during our assessment. Patients told us that the tumble drier on Rose ward had been out of order for 2 days. Maintenance staff had unsuccessfully attempted to fix the tumble drier. Five patients told us that repairs by maintenance can take some time. One patient told us that repairs can "take months" and another 2 patients told us that repairs took a long time. One patient told us that the washing machine on Rose ward had been out of action for 28 days but was now repaired. The provider however gave us evidence that it was out of action for 14 days.”

Two members of staff on Prichard ward were unable to tell us where the ligature cutters were located on the ward and 5 members of staff told us that they had not seen the wards’ ligature risk assessment. Staff said they worked with patients to be as least restrictive as possible. However, on the day of our assessment none of the patients on Prichard the ward had unrestricted access to hot and cold drinks and snacks. The provider shared their restrictive practice log which indicated that this had been thoroughly risk assessed and documented on the wards restrictive practice log. However, the restrictions had not been individually risk assessed and included in individual patient care plans. This is therefore a blanket restriction. The ward’s restrictive practice log evidence that the management of some risks have been applied on a blanket basis and that individual risk assessments aren’t in place. The restrictive practice log states that snacks and cold drinks aren’t blanket restrictions however they were found during our inspection. We were informed that some male staff when undertaking enhanced observation, will not enter a female patient’s bedroom to accurately assess the patient, to protect them from harm. Therefore, we were not assured that female patients who are on enhanced 1:1 within eyesight observations, are being continually observed.

We undertook a tour of 4 wards and seclusion suites and observed that most areas were clean and well maintained, however the carpet on Rose had been soiled and smelled of urine. However, the provider gave us evidence that this had already been identified, investment agreed and plans in place to replace. We observed one bedroom on Mackaness ward to have a dried brown substance on the floor, ceiling and walls, and the toilet was stained. This was in a patient bedroom, which staff had not been checking regularly. The provider has told us that the dried stains were caused by food. Staff undertook regular safety checks of the environment including morning safety checks. Some equipment had not always been checked in line with the provider’s planned frequency. We found that the weekly emergency equipment weekly checks had not been undertaken on Rose ward on week commencing 21/09/2024 and 06/10 4024. In addition, the daily ligature cutters check on Rose ward, had not been undertaken on more than 30 occasions between 02 October and 19 November 2024.

All wards had a full ligature risk assessment in place which included both the ward and external courtyard areas. The provider had effective systems in place for enhanced observations, however not all patients’ safety had been maintained when under enhanced observations. According to the divisional clinical governance meeting minutes, in November 2024, there were 38 self-harm incidents whilst patients were under enhanced observations. These self-harm incidents include attempted self-harm, and all types of enhanced observations, including intermittent observations. Staff had recorded in clinical governance meeting minutes that ‘observations are in place to prevent serious harm and that we are not able to stop some of the patients from self-harming without using long term mechanical restraint.’

Patients and staff at all levels spoke to us about staffing being a concern. We spoke with 15 patients; 8 patients (53%) told us that staffing levels on the ward were a concern. Three patients told us that ‘sometimes you often won’t see staff in communal areas for some hours. A fourth patient told us that ‘staffing is a joke, adding “often I can’t even see a staff member”, whilst a fifth patient told us that “I come out of my room at times and cannot see a staff member”. Two patients told us that there were “a lot of staff around today which is very unusual’. A sixth patient told us that staff are always busy – they are either in the office or on observations. Ten patients told us that that they were bored, that activities were often cancelled, and that they were not always able to access authorised section 17 leave. Between June and November 4 patients raised complaints regarding a lack of access to activities and or leave. Patients raised concerns about shortages of staff at the Mackaness community meeting held on 21 November 2024. According to the divisional clinical governance meeting minutes (November 2024), patients on Bracken had received around 20 hours offered a week which is below the target of 25.5 hours.

During our assessment we spoke to a random sample of 27 members of staff. Fourteen staff members (52%), spoke to us about the difficulties associated with staffing levels. Staff used descriptions including” it’s awful”, “staffing is ‘a real issue”, and that “leave and activities are being cancelled”. Staff spoke to us about the difficulty of not having enough permanent staff on the ward and the associated high use of agency staff. One staff member told us that the main problem in attending to patients' immediate needs, was due to staffing levels. We were told that due to a lack of experienced staff, some nurses had been rapidly promoted to deputy and ward manager posts very quickly. We were told that consequently some senior staff on the wards did not possess the required skills and competencies to safely run a ward. However, the provider has shared details of their ward manager development programme, which has been running since July 2024 and is mandatory for all managers to attend. The provider has advised that the newest managers were prioritised to attend the first cohorts. Managers had documented these concerns in the divisional clinical governance meeting minutes for November 2024 which stated that ‘Managerial changes have effects of the ward. We do not have enough experienced ward managers and deputy ward managers therefore we have to spread available resources.’ Staff told us that there were problems finding nursing staff for Bracken ward.

During our assessment we saw that staff were constantly busy either with patient observations or other allocated tasks. We observed that when an inspector was in the ward’s communal area, that no ward staff were visible. The provider told us that this was due to the staff member being interviewed by inspectors. However, this mirrored concerns raised by staff regarding a lack of staff availability in communal ward areas. A review of patient records confirmed that patients had been unable to attend sessions or go out on section 17 leave due to staffing levels.

As of November 2024, across all wards, there were a total of 44 out of 291 posts which had not yet been filled (15%). This included 34 healthcare assistants and 11 registered nurse posts. However, the provider told us that 15.5 whole time equivalent (WTE) healthcare assistants and 4 (WTE) registered nurses have been appointed. When these new starters commence employment, this will leave a total of 25 WTE posts vacant (18 healthcare assistants and 7 registered nurses - 8.5%). This number is based on the new establishment levels identified following a review of the staffing establishment. The average percentage for turnover of staff June to November 2024 was 10% and the average percentage of sickness was 7.6%. The lowest percentage sickness was 2.8% on Cranford ward, followed by 16.2% on Bracken ward. The highest sickness on the community residential homes was 18.3% on 23 The Avenue (which had a total staffing establishment at the time of assessment of 9 healthcare assistants). Staff received regular monthly clinical and managerial supervision. All staff were in receipt of clinical supervision. The supervision rates for the medium secure wards in October 2024 was 100%.

Staff we spoke with were aware of infection prevention and control systems and processes and were compliant with requirements.

The provider had an effective approach to assessing and managing the risk of infection, which is in line with current relevant national guidance. We saw staff adhered to infection control practices. All staff were bare below the elbows and were not wearing jewellery or nail varnish. The wards had access to hand sanitisers on entry to and exit from the wards.

The provider undertakes a monthly audit of hand hygiene, waste management and sharps. Staff reviewed 27 areas across 11 wards. Wards scored 100% in 23 domains, over 90% in 3 domains and a score of 83% on Rose in October 2024. For the period 2024/25, 3 peer review audits have been completed for medium secure wards by the IPC team for Bracken, Fairbairn and Mackaness wards. The total compliance scores for all domains were over 75%.

Nine patients spoke to us about their medications. Six patients (66%) told us that staff explain their medication with them. Patients we spoke with told us they could have access to specific medicines information, although none of the patients interviewed told us that they had received information about their medications. Whilst the provider advised us that patients have the opportunity to talk through their medication at weekly care co-ordinator sessions and ward rounds, this was not patients’ experience.’ Patients told us that their leave had been cancelled due to positive urine ‘dip stick’ drug tests, which had later proved to be negative following a urine sample test. The provider explained that prior to any temporary suspension of leave, a comprehensive clinical risk assessment takes places in line with policy. A change of result would have resulted in a further risk assessment, and the leave reinstated if safe to do so. The provider was aware of these concerns. In the clinical governance meeting November 2024, it was reported that ‘drug test kits have been giving unclear results when testing for spice'. The provider has shared evidence that the dipstick accuracy was highly accurate, with accuracy levels of 100% for cannabis, and 98% for K2-AB (spice).

Staff told us that the electronic prescribing system (EPMA) was ‘really good’. We found no evidence of any drug errors. Staff told us that the system ‘goes offline’ on a regular basis. However, the provider gave us evidence that this is not a regular occurrence, having only occurred twice in the last 6 months. The provider has contingency plans in place for this. The patient’s prescription can be found on the patients’ electronic health record (RIO), and in line with the providers' contingency plan, we observed staff using RIO to administer medication to 2 patients when EPMA was not available. Staff signed the administration cards retrospectively. However, despite staff having to sign for administered medicines retrospectively, there were no adverse effects or impact to the patient in any way.

During our assessment, we reviewed 30 prescription charts and reviewed the clinics on all 4 wards visited. We saw all medicines were stored appropriately. Staff completed temperature checks of the clinic room and the medicines fridge. We saw that the EPMA had ‘gone offline’ on 20 November am for approximately 40-45 minutes. The system had also gone down the previous day (this was due to a power cut). Therefore, staff could not access patients' prescription charts on EPMA, however could be viewed on RIO in line with the provider's contingency plan. We observed staff administer drugs to 2 patients while the system was down, they did this using RIO, and this is in line with the contingency plans. The frequency of EPMA going offline was not clear, as staff gave us differing accounts from frequent to not often. However, the provider gave us evidence that this is not a regular occurrence.

There was a medicines administration policy in place. The provider has contingency measures in place for when the electronic prescribing system goes offline. This was not followed in 2 instances where patients were administered medication when the electronic prescribing system was ‘offline’. Pharmacy completed 3 monthly medication management audits on the wards, the outcome of which had been discussed in clinical governance meetings.