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

This means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

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.

Managers fostered a proactive and positive culture of safety based on openness and honesty, in which concerns were listened to and, safety events were investigated and reported. Lessons learned were used as opportunities to support, mentor staff and embed good practices. Incidents were logged, discussed and reviewed in the morning risk meetings, handovers and clinical governance meetings.

The use of appropriate systems and governance processes, incidents and complaints were effectively managed to promote learning and improvement. Staff understood the processes and importance of raising complaints and feedback, they supported patients, relatives and carers to raise concerns and to understand the processes.

Staff had access to a range of policies and procedures for additional guidance as well as support from managers. There was a clear structure around whistle blowing and access to a Freedom to Speak Up Guardians, ward managers supported and trained each staff member to become a champion of a key aspect of the service such as infection control.

Patients we spoke with felt safe on the wards and were supported to understand and manage their risks. Some patients we spoke with told us that staff would spend time with them following incidents, providing emotional support and ensuring that they felt safe on the ward.

Managers told us they and members of the multi-disciplinary team reviewed and assessed referrals into the service to ensure the care and support available was suitable for the patient. At the time of our assessment there was an NHS directive to accept referrals who were within a 50-mile radius to help ensure patients could keep in contact with their families and community care teams.

Appropriate systems and governance processes supported safe admissions, discharges and transfers of care. Staff had a good understanding of the processes and policies to ensure transitions between services were manged well.

Staff were aware of potential risks to people across their care journey and worked to ensure sufficient and appropriate information was shared during referral, admission and discharge processes. Staff worked together towards the best outcome for the patient.

Patients we spoke with understood their care and treatment and reason for admission. Some patients did not agree with the reasoning for admission but said staff were helpful in explaining information to them and worked towards discharge.

Patients we spoke with felt safe and supported to understand and manage any risks. Staff we spoke with were knowledgeable about safeguarding and any potential safeguarding concerns were discussed in morning risk meetings, handovers, clinical governance and multidisciplinary meetings.

The staff we spoke with told us how they would recognise a safeguarding concern and how they would protect patients and staff from abuse, including how and who they should report their concerns to. Staff were aware of the anonymous call system implemented by the service where staff could raise complaints or concerns confidently.

The service had safeguarding leads who supported the management team by submitting safeguarding concerns, kept the team up to date with changes in policy and provided advice and support to staff. At the time of our assessment staff had a 100% completion rate for level 3 safeguarding training.

Staff and managers had a clear understanding of safeguarding, the Mental Capacity Act (MCA) and the Deprivation of Liberty Safeguards (DoLS) with information about safeguarding and how to raise concerns on displayed in staff and patient areas.

All patients we spoke with felt safe and supported to manage their risks. Patients felt confident to raise any concerns they had to staff and were involved in their care and treatment. Appropriate systems and governance processes were in place to promote and ensure good risk management. Weekly community meetings enabled patients to provide feedback into their care and raise any concerns with support from advocates.

Staff were aware of the individual risks of each patient, and any changes in risk were updated in patient records, care plans and risk assessments, and information relayed at staff handovers. We reviewed 9 patient records and all of them had an up-to-date risk assessment in place. Risk assessments covered key areas and captured relevant information to support the ongoing management of risk.

The wards did not have any blanket restrictions, and staff regularly reviewed any restrictions to ensure it was clinically justified. Outdoor areas and games rooms were open with staff supervision. Individual patient restrictions were kept to a minimum and appropriately care planned. Staff told us they worked closely with patients to manage their risks and would prioritise de-escalation techniques over restrictive interventions.

Each ward had access to a seclusion room. At the time of our assessment only 1 out of the 3 rooms were being used but were functional and could be utilised when required. Staff and management were very clear they try other means of support before placing a patient in seclusion. We spoke to a patient who was secluded at the time of our assessment, and he told us he felt safe and understood that others were safe from him as he was unwell. They were thankful of the staff observing them and said that they were very good staff members.

Patients we spoke with did not raise any concerns regarding the environment and said the facilities on the wards were clean and well maintained. One patient said the environment was clean, and they were thankful the cleaning team helped them to clean their bedroom and bathroom.

Staff we spoke with displayed a good understanding of environmental risks. They were aware of ligature risk assessments that had been completed and described how they used individual risk assessments, care planning and observations to manage environmental risk. Staff were aware of fire evacuation procedures and reported regular drills and alarm tests.

Seclusion rooms allowed clear observations of the patient, had two-way communication, toilet facilities and a clock.

Managers and staff, we spoke with raised concerns regarding the environments in Bayley ward that had tea stains on the ceilings and walls. Due to the material of the walls, they could not be cleaned by the staff but would require wall panels to be replaced. Staff told us of their ongoing attempts and requests to update the outdoor and communal areas in all 3 wards. Staff made all efforts to clean the ward and create inviting spaces for the patients by using initiatives such as art posters to decorate the wards. Plans and requests for paint and decorating to be completed within the wards and outdoor spaces were submitted but had yet to be completed by the contractors.

No ligature anchor points were seen on the wards and in communal areas, with ligature knifes kept in wall mounted yellow boxes in specific areas within the wards. All boxes were locked, and every staff member had a universal key that would grant access to each box across the 3 wards.

The ward offices were situated with a good view of the wards which allowed staff in the office to observe the environment and provide support where needed. Naseby ward had a different layout out compared to the other two wards with the bedroom areas on a second floor. The bedroom area was always open and available to patients but was not accessible to patients whose mobility was limited and those who used a wheelchair, as there was no lift in place. Some patients told us it felt like home and not a ward due to the bedrooms being upstairs. This did not allow staff to observe all parts of the ward. This was mitigated using mirrors and staff members were always present in specific areas.

Managers ensured that only appropriate referrals were accepted to ensure patient and staff safety and well-being. The ward environment was clean, well-maintained, and appropriate for use.

Managers told us safe staffing numbers were in place, which could be adjusted to reflect patient needs. Wards were very rarely short staffed due to the low numbers of patients across the 3 wards. There was capacity to increase staff when required if additional patients were admitted, but managers told us there was an ongoing recruitment drive within the service. From December 2024 to March 2025 there was a turnover rate of 4.3% of staff across all wards.

Managers had calculated the number and grade of nurses and healthcare assistants required on each ward. Staffing levels could be adjusted dependent on factors such as the number of patients on the ward, nursing observations, and patient medical leave. During the day of our visit, it was observed that Bayley ward was initially operating on 2 nurses and 2 healthcare assistants until Heygate ward were able to support by providing a healthcare assistant with PICU experience to support for the rest of the shift. Assurances were provided to patient and staff safety, stating that both acute wards will support each other with staffing and patient care. Staff and patients did not share concerns with staffing numbers.

At the time of our assessment the use of bank and agency staff was low due to low patient numbers. Managers actively limited their use of bank and agency staff and always requested staff familiar with the service and who had previously worked on the wards. This did not cause any issues as they were regular staff who knew the environment and patients. Bank and agency staff received a full induction and were briefed about the service and patients prior to starting their shift.

Currently the staffing figures and use of agency staff were good and appropriate to match the low patient numbers. The provider assured us that the staffing numbers could be increased when required to support the increase in patient admissions. We reviewed staffing figures from January to March 2025, and all 3 wards had the correct staff planned for that day with some having higher staffing numbers than planned.

Across the 540 shifts throughout that period, 135 shifts used agency staff, which equated to 25%. However, from the 540 shifts only 43 shifts required more than one agency staff member with the rest being permanent staff. The service assured us that most agency workers were regular to the service and therefore knew patients and their needs. The service always met safe staffing levels and managers always ensured there were regular permanent staff on each shift on every ward.

There were no safety issues in relation to short staffing. We saw sufficient staff were in place to complete prescribed patient observations, complete observations in communal areas and to provide patient support outside of the observational demands, including 1 to 1 support sessions. Patient activities and leave were ongoing with staff seen engaging with patients and occupational therapists arranging sessions as planned.

Staff completed and kept up-to-date with their mandatory and training. Compliance with mandatory training was above 96% on all wards, with non-mandatory training at 97% across the 3 wards.

Staff and patients did not raise any concerns in relation to infection prevention and control (IPC).

Staff were aware of their duties and how to promote a positive and safe living environment for the patients.

Wards were clean and well-maintained. Staff had access to infection prevention and control resources including personal protective equipment, hand gel and cleaning materials. We observed staff following infection control principles including using handwash. Cleaning records were up-to-date, and clinical equipment was appropriately cleaned and maintained. Domestic staff were visible during the assessment.

The service completed infection prevention and control checks and audits to ensure required standards were met. Staff had access to an infection prevention and control policy and support and guidance was readily available. Mandatory compliance infection prevention and control training was above 96% on all wards.

Patients we spoke with felt they were supported and kept up to date with their care and treatment. Patients informed us that their medicines were explained clearly to them and they were actively involved in their care and treatment.

Staff followed systems and processes to prescribe and store medicines safely. All clinic rooms were clean, and staff had access to all appropriate equipment. Routine audits of medicines were completed by the hospital pharmacy department each month.

We reviewed 9 prescription charts. Medicines were prescribed, administered and recorded in line with national guidance including the management of controlled medicines.

Medicines and related paperwork were stored correctly within the clinic room Controlled drugs and fridge items were stored according to legislation and policy. Patients medicines’ records contained information staff needed to administer medicines safely such as allergies. Medicines prescribed to be given when required (PRN) had clear indications and maximum doses recorded. Staff recorded the times that these medicines were given to ensure that the safe gap between doses was maintained. Medicines were administered safely.

Staff reviewed each patient’s medicines regularly and provided advice to patients and carers about their medicines. Multidisciplinary teams conducted a thorough review of each patient’s medication at weekly ward rounds.

Staff completed medicines records accurately and kept them up-to-date. Staff completed medicines administration records.