Archived: 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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. During this inspection we considered how people were receiving services in line with Right Support, Right Care, Right Culture. At our last inspection of medium secure, CAMHS and LD/A, we rated this key question requires improvement. At this inspection the rating has changed to inadequate. This meant people were not safe and were at risk of avoidable harm.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

The provider did not have a proactive and positive culture of safety based on openness and honesty. Staff did not listen to concerns about safety and did not investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

Staff had not always reported all incidents in line with provider policy. Staff recorded incidents on an electronic incident reporting system. During our inspection we reviewed 71 records. During our review of patient records, we saw details of seven incidents, for which there had been no corresponding incident report raised on the provider’s incident reporting system. We also observed that the description of recorded incidents did not always match what we observed on controlled circuit television (CCTV). For example, in one incident report staff had recorded that a patient had assaulted a staff member. A review of CCTV showed that the patient had not in fact laid hands on the staff member.

At the time of our inspection, not all incidents had been reviewed and signed off by the ward manager in a timely manner. We viewed a summary of current incidents, which showed that out of 303 records, 254 in the holding area awaiting review were overdue and of the 1,610 records being reviewed, 1,552 were overdue.

Whilst immediate actions were undertaken (via daily MDT meetings, handovers and huddles), this reduced the opportunity for wider learning and taking appropriate steps to prevent a reoccurrence of incidents.

Incidents recorded by staff on the incident reporting system, were not sufficiently detailed to consistently identify learning opportunities. For example, incident records completed by staff lacked detail to enable the management team to effectively review and complete a functional analysis (understanding the reasons for patient behaviours). This meant learning opportunities to review and reduce risks to people were often missed.

The provider had systems and processes in place for the sharing of learning from incidents. During our inspection, we observed several safety notices on staff notice boards and evidence of discussion in clinical governance meetings. However, due to the high use of temporary staff, not all staff we spoke with were aware of lessons learned from recent incidents.

Learning was shared electronically via emails to all wards. Ward managers were then required to share the learning across their teams, both electronically, and in paper form (each ward has its own folder), which staff are required to sign to ensure staff are reading and understanding.

The provider did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services

We found that staff did not always follow the providers policy for enhanced observations. For example, staff were not always undertaking observations in line with prescribed observation levels, they were not always sitting within eyesight of patients who were under within eyesight enhanced observations.

According to provider’s minutes from community and clinical governance meetings some staff had been observed paying games and reading. It was recorded in the team meeting on Seacole ward (22 February 2025), that staff “should not be reading newspapers on enhanced observations”. The community meeting for 5 March 2025 on Seacole ward states, “Night staff are still being observed with blankets, taking shoes and socks off. One patient told us that staff had been sleeping whilst undertaking enhanced observations.

We reviewed a random sample of CCTV footage from Seacole ward from the early hours of 15 March 2025. This focused-on timeframes of 1 to 2am, 3 to 4am, as well as 4 to 5am. During this we identified that staff undertaking observations were not actively observing and were frequently noted to be reading books, playing games or using laptop computers. We also found that observations for two patients were recorded on the e-observation system as having been completed, but CCTV footage evidenced no observations were completed during the timeframes. In addition, staff were not bare below the elbow and wearing clothing such as wool hats.

We found patients were at risk of harm despite either being prescribed and receiving enhanced observations, or as a result of observations not being put in place to mitigate known risks. Data supplied by the provider showed, in the 12-month period 01 April 2024 to 20 March 2025, there had been 28 incidents where there had been harm to patients whilst being supported through enhanced support. This has been the subject of an internal review. For example, on Seacole ward one patient had self-harmed 10 times since 18 February 2025. Whilst these incidents occurred the patient was being nursed via enhanced observations with 2 staff members required to be at arm’s length during the day and 2 staff members required to be within eyesight at night.

Staff were not always completing enhanced observations in line with the prescribed frequency. The provider shared figures in relation to the timings that staff recorded enhanced observations on multiple wards. For example, the data for the period 1 January to 31 March 2025, showed that on Cranford ward 55% of observations were recorded over 5 minutes later than required and 45% were recorded over 10 minutes later than required. For the same period on Fairbairn ward, 44% of observations were recorded over 5 minutes later than required and 33% were recorded over 10 minutes later than required.

People using the service told us staff involved them and supported them with their transition into the service. They told us staff discussed future plans regarding moving on from the service during multi-disciplinary reviews. Most patients had discharge care plans in place.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately.

Systems and processes that recorded, monitored and reviewed incidents were not effective to ensure appropriate risk mitigations could be implemented to minimise the risk of reoccurrence. The provider had not always ensured that patient’s safety had been maintained. Thirteen service users on Willow, Berry and Bracken wards spoke about having been bullied by co-service users. Some patients told us that they did not feel safe on the wards. For example, 2 patients told us they had faced bullying involving racist remarks. Another patient told us they had been assaulted and that they were being punched by a fellow patient for about 10 minutes before staff intervened. The incident is currently being investigated by the police; however, the patient who committed the assault remains on the same ward as the victim. The patient told us that ‘violence happens; at least once a week’.

Seven patients spoke about being bullied by co-patients. Patients also told us that they had been assaulted by fellow patients including incidents of harm or abuse from other patients. For example, one patient on Rose ward said they did not feel safe on the ward because of repeated discrimination from another patient. The provider has since advised that in response a social worker spoke to the patient and that the social worker had arranged a mediation session with another patient on the ward following an assault on them.

One patient on Berry ward told us they had experienced bullying from peers, and that staff had been made aware of this. The bullying was described as being on and off. The patient told us staff kept a close eye on them (the patients) so that they could intervene if they saw anything inappropriate, which they felt pleased about. On Willow ward, one patient told us there had been a serious incident where only one staff member was present in the dining area. The patient told us they “had to intervene in a fight”. The patient told us “It was a severe incident, and I no longer feel safe on the ward. Many patients are worried”. The provider has since provided evidence that staff had intervened and managed the incident. One patient on Spencer North ward told us they had been assaulted by another patient, “the attack happened in the dining room while staff were in the office. It took them a long time to intervene. The other patient punched, kicked, and hit me for about 10 minutes before staff stepped in. The attacker is still on the ward, and I do not feel safe. I have had to stay in my room more often because I fear another attack. No doctor has assessed the injuries on my face”. However, the provider has told us that they have looked into this concern and have found no evidence to support it.

One relative told us that their relative on Meadow ward was “fearful of some of their peers and therefore avoided communal areas as well as group activities”. The relative said staff were aware of this but “it does not feel like it has been resolved”. The provider has since told us that alternative sessions had been offered to this patient to support in therapeutic activity. Six patients accessing Deaf services told us they would like to move to an alternative placement. Two of those patients told us they would prefer to return to prison rather than stay at St Andrews Healthcare. However, the MyVoice survey results for April 2025 indicated that 71% of patient across the service felt safe.

We reviewed community meeting minutes and found that patients across different wards had repeatedly voiced feeling unsafe. Patients can be at risk of psychological harm if they do not feel safe in their surroundings. In addition to this, not feeling safe can impact on patients engaging in therapeutic activities to support their treatment.

We identified several alleged incidents of staff bullying, abusing and/or being rude or verbally aggressive to patients. According to the incident data supplied by the provider, between 1 October 2024 and 13 March 2025, there had been 21 incidents of alleged abuse by staff or inappropriate language used by staff.

Patients also alleged bullying from staff (telling us that staff would threaten to remove personal items if they were not compliant with medication). One patient on Spencer North ward told us, “There have been reports of staff members showing hostility toward patients; this is currently under investigation”.

The findings of the providers’ safeguarding audit (published 20 December 2024) also found that some patients did not feel safe. The summary of the audit report was that ‘a quarter of the patients who responded, are not feeling safe in their wards, the main reason reported for this being due to aggression from other patients’.

We reviewed 4 incidents of CCTV, involving restraints, following some feedback given to us by people using the service. We reviewed 1 incident on Acorn ward, 1 on Oak ward, and 2 on Meadow ward. We observed staff did not fully adhere to approved training techniques in 3 out of the 4 incidents viewed. This was bought to the attention of senior leaders, who took relevant action. This included commencement of internal investigations and safeguarding referrals to the local authority when deemed necessary. Two senior staff members informed us that some service users were kept in seclusion and extra care due to a lack of staff to effectively safely maintain service users on the wards.

We were concerned that patients accessing services for people with a learning disability and/or autistic people were not adequately protected from a risk of harm or abuse. Some people had not experienced safe and kind treatment from staff, which was reflected within safeguarding concerns raised by people using the service against staff.

During our assessment, we observed numerous examples of restrictive practice across all services. The Mental Health Act Code of Practice, at “blanket restrictions should be avoided unless they can be justified as necessary and proportionate responses to risks identified for particular individuals”. Staff had not ensured that all blanket restrictions had been individually assessed, in line with best practice. During our inspection, we observed numerous examples of restrictive practice. The provider has a blanket restrictions log which identifies the blanket restrictions for each ward. These included no free access to hot and cold drinks and snacks, some locked doors to quiet rooms, patients unable to access their bedrooms during the day, and restrictions around access to vapes. These restrictions applied to all patients on the ward irrelevant of their individual presentation. Vaping times were set across some of the wards. For example, on Oak ward, the courtyard was kept locked, meaning staff had to open it and be present when people wanted fresh air. On Berry ward, staff explained that the activity/games room was kept locked due to a previous sexual safety incident. On Meadow ward, people told us they were reliant upon staff to get them a hot drink as they had no free access to hot water. We were concerned that this restriction had been placed upon people because of the staffing levels and acuity. Post assessment, the provider confirmed that staff provided regular hot water in a flask which they refilled regularly.

Staff have recorded in the restrictive practice log for Sunley Ward (November 2024) that takeaway access is an ‘individually assessed restriction’. However, two people at Sunley ward told us they were only allowed to order a takeaway once a month. Staff had explained to them this was because some people on the ward had put on weight. The 2 people we spoke with said this was unfair to impose this onto everybody.

Most staff received training on how to recognise and report abuse, appropriate for their role. The mean average for safeguarding level 3 across all wards was 92%, safeguarding level 3 (online) was 95% and safeguarding children and young people was 94%. However, the level 3 safeguarding training on Willow ward in March 2025 was 71%.

During 2024, staff in the medium secure directorate had raised 111 concerns to the local authority. Of the 111 safeguarding referrals raised, 64 (58%), required further actions and the outcome of screening for 42 referrals (38%), was not yet known. These figures indicate that actions were required in over half of the safeguarding referrals. Within the LDA service, over the 6-month period from 1 September 2024 to 21 March 2025, there were 65 safeguarding incidents recorded that were referred to the local authority. The highest number of concerns reported across the LDA wards related to patient-to-patient physical assault (33% of all recoded incidents), followed by 29% relating to deliberate self-harm (DSH). The provider has confirmed that patients had come to harm because of staff, for example not observing the patients correctly. The third highest category for safeguarding referrals were allegations of abuse against staff at 13%.

We observed seven entries within patients’ progress notes, where a risk incident had occurred, however, review of the records showed that an associated incident form had not always been completed. Also, when reviewing patient records and CCTV, we found that the description of recorded incidents did not always match the description of the incident when viewed on CCTV. Where incidents had been reported, some incident records completed by staff lacked detail to enable the management team to effectively review and complete a functional analysis. This meant learning opportunities to review and reduce risks to people were missed.

Most staff knew how to recognise adults and children at risk of or suffering harm and worked with other agencies to protect them. The provider had processes in place for tracking the progress of safeguarding referrals.

There were a high number of incidents. The total number of incidents reported across the LDA, CAMHS, medium and low secure wards between 1/09/2024 to 21/03/2025, were 7752, of which, 1768 related to medium secure, 4098 LDA, 123 low secure and 1763 CAMHS. The highest number of incidents reported across the forensic services between 01 September 2024 to 21 March 2025 was across the LDA wards, with 4098 incidents reported. However, the rate of rapid tranquillisation usage (per 1000 occupied bed days remained lower that 5’. Figures shared by the provider has shown that there was an increase in the number of incidents between July 2024 in medium secure, (70) to February 2025 (80). The number of incidents which had resulted in the use of force remained below 15 in July 2024 and February 2025. Although the number of incidents which had resulted in harm (level 3 or above), had increased from July 2024 (0.4) to February 2025 (0.8). We had concerns as to whether all people using the service were being adequately protected from abuse. However, the provider has shared benchmarking figures with another medium secure provider. This shows that the number of incidents (per 100 occupied bed days was 1.2, compared with 2.9, and the number of patient restraints (per 100 occupied bed days was 3.6 compared with 7.7. People told us if they felt unsafe on the wards, they would talk with a staff member or bring this up in their regular community meetings.

The number of incidents of violence recorded for the 6 month period October 2024 to March 2025, were at or higher than the incidents of violence over the previous 6 month period. The highest number of incidents recorded was 75 (October 2024) and the lowest was 47 (December 2024), which was the highest number recorded in the previous 6 month period. Patients had care plans in place for the management of violence and aggression, however; to deescalate situations effectively, staff must be skilled, know and understand the patient and be present in clinical areas. However, training in the prevention of violence and aggression is not mandatory. The Royal College of Psychiatrists’ national standards for forensic mental health services, states that staff must receive training on risk assessment and risk management. This includes prevention and management of aggression and violence which is refreshed in accordance with local guidelines. The high number of incidents appear to be a symptom of the concerns identified during the inspection, in relation to current staff levels, staff skills and competencies and high use of non-regular staff.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We did not feel that all wards promoted and provided a safe and consistent atmosphere for people using the service. On Fairbairn ward, interpreters were not always available and there were not enough staff trained in BSL. Consequently, difficulties in ensuring effective communication had led to incidents on the ward.

Staff completed risk assessments for each patient on admission using a recognised risk assessment tool and reviewed this regularly. However, staff had not updated risk assessments immediately after every incident. Patient risks were generally updated in the patent’s records during the multi-disciplinary meeting which took place every 2 weeks. Patient risks were however discussed at the daily huddle meetings and during most handovers.

Patients had care plans and risk assessments in place which were reviewed at regular intervals by staff. Risk care plans were reflective of patient risks including risks of violence and aggression, but did not always contain details of the most recent clinical risk incidents. However, not all non-regular staff we spoke with knew the contents in detail or had full access to electronic records. This included one nurse in charge we spoke with. The nurse told us that other regular staff knew the patients well and they would refer to them for support if needed.

Patients also had PBS plans in place. However, PBS plans reviewed did not fully meet national guidance. The plans did not always have clearly identified primary preventative strategies which focused on improvement of quality of life and ensuring needs were met. Some plans could have included more detailed responses such as de-escalation techniques, distraction, diversion and sometimes disengagement to be used by staff when a person starts to become anxious, aroused or distressed. There was a lack of individual prescribed safe holds for staff to use to ensure they were the least restrictive option.

Some people shared experiences of staff creating their PBS plans with them to help them manage any risks. People were able to share what staff could do to help them during times of distress. This was evident in the PBS plans reviewed. However, staff had not always followed people’s PBS plan. For example, we reviewed an incident, during which staff did not use approved techniques to restrain the patient. The physical intervention used was not in line with staff training or the patient’s PBS plan.

Across the wards there were numerous people being cared for in long-term segregation (LTS). The provider adhered to the Mental Health Act Code of Practice, to ensure that patients in long term segregation were receiving the least restrictive care as possible in identified areas, privacy and dignity was maintained, relevant care plans and reintegration plans were in place, activity and therapy were offered, and relevant people (including patient families, commissioners and the local authority) had been notified.

There was a process in place across all forensic services and CAMHs ward, for staff and people using the service to attend de-briefs to discuss incidents and reflect upon any learning.

“The provider has shared information that evidences that out of 135 incidents (during the period January to April 2025), 51 de-briefs took place with patients. This is a compliance rate of 38%. However, of the remaining 84 incidents, 50 debriefs were offered, however the patient declined. This confirms we have a compliance rate of 75% in patient de-briefs. All these incidents (100%) included a staff de-brief.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

We found numerous outstanding maintenance issues on the wards which had not been actioned resulting in patients being exposed to unnecessary risks or having to reside in unacceptable conditions with inadequate facilities. Therefore, we were not assured that arrangements in place to monitor the safety and upkeep of the premises were always effective and completed in a timely way. We identified 2 maintenance issues in the extra care area on Acorn ward that required immediate attention. This included some rusty fittings and some metal sharp edges in the enclosed outside area, which could potentially cause harm. We saw a wire trailing from the lounge out into the outside area, which was a trip hazard and a potential ligature risk. We also saw that a ceiling on Acorn ward had lots of peeling paint and what looked to be like some water damage. These were escalated on site to senior leaders who took immediate action. We were concerned that these issues had not been identified or actioned previously. It was unclear how long these issues had been outstanding. We viewed the maintenance log for Acorn ward, however there was no entry (prior to the CQC visit) of the issue having been reported.

Some people on Meadow ward spoke to us about the dining room. One person told us that part of it had been boarded off for over 6 months. We saw that part of the dining room was boarded off. This reduced the size of the dining area, and as a result, there was no natural light going into the room, as the skylights were blocked. One person using the service described this room as like “being in a coffin”. We asked senior staff about when this was likely to be repaired. We were told that this was a complex building defect that required significant investigation and that works had been planned for May 2025.”

Across the LDA wards visited, we were told that some people had reported problems with their showers being cold, some problems with shower heads, shower drains and blocked sinks. These issues had been reported by different people across different wards, to include Acorn, Oak, Meadow, Berry and Sunley wards. We were concerned that issues were not being actioned in a timely way, with many seeming to be of a similar theme, around plumbing. Staff were made aware of these concerns, which were going to be escalated to the maintenance team.

Across the medium secure wards, we found the same issues in relation to poor maintenance. For example, leaks of toilets and showers, a leaking roof and patients being unable to access hot water on Cranford ward. We also observed mould on the ceiling, stained and marked flooring leading to a lack of cleanliness, poor standards of the environment which led to potential infection prevention and control, risks.

On Rose ward, the area just inside the main ward had a strong smell of urine. Staff told us that this had been identified and reported some time ago, however the carpet had not been replaced. We also found that fridge and room temperatures had not always been recorded. On Willow ward, we found that the pulse oximeter had not been calibrated in line with the required frequency. This was despite an incident having taken place involving a medical emergency, during which the pulse oximeter did not work. The lessons learned poster advised staff that ‘due to item not being in working order, this had impacted on staff attending to the medical emergency being able to obtain physical health observations, further impacting on timely and appropriate intervention’. However, this had not resulted in the pulse oximeter being calibrated which could lead to another incident in the future which could result in a serious outcome.

Staff had completed risk assessments of all ward areas, however had not removed or reduced all environmental risks. For example, we saw evidence of wires being left in an activity room, a COSHH cupboard was left unlocked in a patient’ laundry room, 3 screws had been left on the wall near the examination couch and there was a loose lighting in a ward courtyard. We reviewed the maintenance log and could not see that this concern had been raised prior to our inspection.

Trailing cords can be a trip hazard as well as a potential ligature risk. Accessible sharp edges on fittings could be used by service users to engage in deliberate self-harm. Uncalibrated medical equipment might lead to equipment not being in full working order which may impact upon physical health assessments.

Staff could not observe patients in all parts of the wards, as there was not good visibility of all ward areas. The provider had plans to mitigate these risks by having mirrors in blind spots and having staff presence on the ward to observe all ward areas. However, due to staffing levels, having a staff present in all ward areas could not be assured. The provider shared details of complaints made by patients. This showed that a patient had raised concerns relating to an incident in a bedroom corridor when no staff were present. Patients also told us that there was often a lack of staff presence in some ward areas.

In line with best practice, LDA wards should create a safe, accessible and sensory friendly environment that promotes wellbeing and minimises anxiety. Two people on different wards told us they often experienced ‘sensory overload’ with the general noise of the wards, and the TVs in the lounge constantly on. Both wards had the TV’s on in the main lounge at the time of our visit. A third person using the service told us the ward can be too noisy. One nurse on Acorn ward was a responder across the wards. During an interview their alarm kept going off loudly. This was observed intermittently throughout the morning, including when the nurse was in communal areas and walking through the ward. The staff member did not appear to have an awareness that it was noisy and may impact negatively upon some people on the ward.

However, all the wards visited provided quiet spaces, where people could go if they felt overwhelmed or distressed. We saw LED lighting along bedroom corridors which were used on occasions to reduce glare and promote calmness. We saw temperature controls on walls in rooms used by people so the temperature could be adjusted. Each ward had clear signage along with relevant timetables of ward activities and routines, in accessible formats. Wards had a sensory room, although it was unclear how often these were used. Nursing staff told us that these were used mainly by the occupational therapists with people on the wards. People using the service were able to go into these rooms and sit quietly if they wanted to.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

We were not assured that staffing levels were sufficient to meet patients’ needs or keep them safe. Patients and staff at all levels spoke to us about their concerns regarding staffing levels and the high use of temporary staff being a concern. This included nursing levels being below agreed levels during shifts, a lack of permanent staff who know the patients and their risks on a shift, the high use of temporary staff, and a lack of occupational therapists. In addition, consultant psychiatrist vacancies were identified as a major risk on the medium secure divisional risk register.

The total number of whole time equivalent (WTE) hours worked across the 9 medium secure wards over the 6-month period 20 September 2024 to 20 March 2025 was 27,584.7, of which 16,389.82 WTE were permanent staff (59.41%). The remaining 11,194.88 WTE (40.59% of shifts), were worked by non-permanent staff; agency (9.9%), workchoice (bank) (15.46%) and overtime (15.21%).

The total number of WTE hours worked across the 2 low secure wards over the 6-month period 20 September 2024 to 20 March 2025 was 3,956 of which 2909 was permanent staff (73.63%). The remaining 1,046 (26.27%) of shifts were worked by workchoice staff (15.41%), who would often have experience of the ward and overtime (9.90%). Agency staff worked 1.04% of shifts.

The total number of WTE hours worked on the CAMHS ward over the 6-month period 20 September 2024 to 20 March 2025 was 5025.8, of which 2,097.54 were permanent staff. The remaining 2,928.26 WTE (56.27%) of shifts, were covered by non-permanent staff were worked by agency (36.08%), workchoice (16.28%) and overtime (5.89%).

The average sickness level as of February 2025 for medium secure wards was 8%, CAMHS was 9.9%, low secure was 4.85% and LD/A was 10.05%, most of which (which according to national benchmarking data) is above the national average sickness levels of 6.3%. The highest sickness level was on Fern ward at 14.6% followed by Marsh ward at 14.3%. The mean average sickness across the services was 8.2%. High levels of sickness have been recorded on the LDA risk register. The provider had control measures in place to mitigate current sickness levels. This included delivery of trauma informed care training, restorative supervision, an increase in recruitment and weekly meetings with human resources (HR).

Staff turnover rates differed across the service. The turnover rate for low secure was zero, medium secure was 0.7% (mean average), LDA (mean average) was 0.63% and CAMHS was 5.1%.

Staff and patients told us that their activities and leave, had been cancelled due to a shortage of staff. Patients stated that they were bored, that activities had been cancelled, and they were not always able to access authorised section 17 leave. We found that the need for improvement in the number of hours of meaningful activities had been identified and documented for action, across the forensic services and CAMHs ward. In February 2025, staff recorded in the clinical governance meeting minutes, that patients across the medium secure wards had not met the 25 hours of offered meaningful activity, which had been developed in response to the patients’ risks and therapeutic needs. Figures showed that the number of hours offered week commencing 5 January 2025 ranged from 14.5 to 7.2, which equates to 58% to 71% less than the contracted requirements. However, according to the MyVoice Data (April 2025, 68% of patients indicated that staff spend enough time with them.

We found that staff had not received adequate training to ensure they could meet the needs of autistic people and people with a learning disability. Five people using the service out of the 18 we spoke with told us that staff were not appropriately trained in autism and did not understand their needs. Two senior staff members told us that the service had identified staff needed more specific training in relation to autism and trauma informed practice. The hospital risk register features a moderate risk, identifying that there is a lack of specialist training in learning disabilities and autism provided to staff across the LDA division. Regular staff were compliant in the basic awareness training (autism and learning disabilities). When we asked staff about this training, all said it was online. Twelve out of 13 (92%) of staff members we spoke with raised concerns regarding a lack of training which related to the patients they supported.

We were told there was a plan in place for 5 staff members across the division to undertake a training course which will enable them to deliver SPELL training to staff. The SPELL framework is the National Autistic Society’s framework for understanding and responding to the needs of autistic people. It is a framework when working with autistic people, known as SPELL (structure, positive approaches and expectations, empathy, low arousal and links. At the time of our inspection, across the LDA division, a total of 12 staff out of 396 had completed this training, equating to just 3%. Of the wards we visited, no staff on Sunley and Meadow wards had received the training. 1 staff member out of 29 on Acorn were trained (3%); 1 staff on Berry out of 31 (3%) and 2 staff out of 53 on Oak ward (4%).

Senior staff told us that they were in the process of rolling out some trauma informed care training. Managers subsequently informed us there had been 2 training sessions offered in February and April, of which 50 out of 396 staff had attended. Many patients across the LDA services had a history of trauma. It is essential that staff understand the impact past trauma has had upon people. This will help them to work with people, understand how certain actions can affect them, and work towards preventing any traumatization. On Oak ward, senior staff had completed a training needs analysis, which identified trauma informed care training was needed for staff. At the time of this assessment there was no confirmed plan in place to deliver this.

On Fairbairn ward (specialist ward for deaf patients), we found that there was a high level of concern regarding staffing. Concerns included the ward not having regular staff (the ward had only 3 regular qualified nurses), staff being moved to other wards, and permanent staff not being British sign language (BSL) trained. Consequently, we found that there was low staff morale on the ward. In response managers had met with the staff to discuss their concerns. Managers told staff that they were surprised to hear about the low morale on the ward. In response managers were taking action through increased monitoring and staff meetings, however these actions had not been effective at the time of our inspection, as there continued to be low morale on the ward. Two nurses told us that they were leaving as frequently there were no permanent registered nurses on duty and that there was a lack of BSL interpreters. One patient had requested to return to prison due to their concerns regarding care and treatment.

Patients and staff told us that there was not always access to interpreters. Staff can request access to interpreters via a booking system. However, there was a lot of unfilled gaps. Staff told us that deaf staff and interpreters were not adequately supported.

The overall appraisal rate for all wards across the forensic service and CAMHs ward, as of 18 April 2024 was 92%. Most wards had appraisal figures above 75%, however the appraisal rate for Oak ward was 3%.

Staff had completed and kept up to date with their mandatory training. Overall, staff compliance with mandatory training across the forensic and CAMHs wards were medium secure at 95%, low secure at 95%, CAMHS at 94% and LDA at 96%. Therefore, the mean mandatory training average across all forensic services and CAMHs ward was 95%.

The mandatory training programme for the forensic and CAMHs wards (including permanent and bank staff) was comprised of 12 training courses including immediate life support, infection control, relational security and safeguarding. However, even though there were 2,022 incidents of violence and aggression for the period 1September 2024 to 21 March 2025, mandatory training did not include the prevention and management of violence and aggression. Training for agency staff is delivered by the relevant agency.

Most managers monitored mandatory training and alerted staff when they needed to update their training. Managers received a regular report showing compliance with mandatory training. This report included details of training that was soon to expire.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

We identified several concerns in relation to infection prevention and control (IPC) practices on the wards. We observed 6 staff members on Cranford ward, Willow ward, and Bracken ward, who were not bare from the elbow. Two staff members were wearing nail varnish and 2 were wearing jewellery. This included managers, medical staff, social workers, occupational therapists and nurses.  This did not adhere to best practice and policy for IPC. Consequently, staff were not taking appropriate measures to prevent the spread of infections in healthcare settings, ensuring patient and staff safety.

We found staff were not always storing food safely or in line with food hygiene requirements, laid out in your policy and infection prevention audit report standards. Poor food hygiene practice will lead to illness in the consumers of the food, most likely with food poisoning. For example, staff were not always labelling food to identify the date the food item had been opened and the associated expiry date. On Willow and Cranford wards, fridge temperatures had not always been recorded, and we found several food items which were out of date. On Seacole ward the therapy kitchen freezer and microwave were dirty. This presented a risk of food contamination or food poisoning. We found staining on the wall in the quiet room. On Rose ward we observed that the clinic floor was not clean. On Cranford ward we found dried faeces on an unused toilet roll dispenser. We also found mouldy food in a staff fridge.

We also found outstanding maintenance issues which could pose an IPC risk. For example, we found damaged and dirty flooring, dirty and stained toilets and sinks and damaged walls. However, the IPC annual audit results looking at the environment, did not mirror our findings. The average annual IPC audit score for LDA wards was 84%, CAMHS and low secure 84%, and medium secure 90%.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

We found medicines were not always administered safely and not all paperwork relating to medicines was accurate or up to date. There were 2 incidents in the 2 months previous to our inspection, where medications were administered to the wrong person. The review of the incidents identified that a lack of familiarity with patients had been identified as an area of concern for both incidents.

Following one of the medication incidents cited above, the patient who had been given the incorrect medication, was transferred to Northampton general hospital. According to the National Institutes of Health (2024), ‘medication errors rank as the most frequent and avoidable source of patient harm.’ Medication errors can result in side effects and serious harm to patients including death. However, the initial response to the error had been well managed, and a safeguarding referral had been completed.

We observed that the medicine round had started earlier than prescribed (at 20:40 instead of 22:30). Consequently, patients were at risks of not receiving their medication at the right frequency. This could result in patients not having the right amount of medicine in their body at the right time to manage their condition.We were informed that this was due to connectivity issues. Staff informed us that the electronic prescribing and administration system is slow at peak times. Therefore, some nurses will try to avoid these peak times for non-time critical medication. Medicines involved included clozapine, lithium, and olanzapine.

A further medicines incident occurred on Rose ward in March 2025, which involved a bank nurse dispensing controlled drugs to a patient. Whilst immediate actions were managed well, the nurse did not follow policy with regards to identifying the patient, and it is unclear how policy was followed which requires a second person to "witness" controlled drug administration. Also, the lack of a handover and last-minute redeployment of the staff member to another ward was stated as a causative factor. We were also aware of an agency staff administration error from the summer 2024 on Sunley ward where incorrect formulation of a medication (methylphenidate) had been administered. Whilst we did see mitigations on the ward to prevent future recurrence, a pattern of errors involving administration by agency/bank staff has emerged. One patient on Cranford had no Clozapine care plan in place.

The controlled drug audit rates for quarter 4 (January to March 20205) highlighted concerns for Seacole ward (65%).

Staff had recorded in the minutes of the medium secure divisional clinical governance meeting (13 January 2025) that ‘there were a high number of medication errors on Mackaness ward, and that ‘this might be due to high numbers of agency nursing staff’.’ The performance table presented at the meeting indicated that there had been in an increase of 3 medication errors in the previous month, and that there had been 12 errors since July 2024. In response two staff members were allocated to look at the themes from the medication errors since July 2024, and plan appropriate support/intervention. We reviewed minutes from the divisional governance meeting from September 2024. No concerns had been raised by managers regarding drug errors until December 2024, when an action was identified to investigate high rates of medication errors. At the January meeting that this investigation had taken place.

A concern was raised about an EpiPen not being prescribed. While staff were aware of the patient’s allergies and use of the EpiPen, it was not recorded in the electronic prescription and medication administration (EPMA) system. Staff were informed by the inspector. When the clinician responsible was informed, the pharmacy team was immediately contacted to re-prescribe this. We were concerned that despite staff being aware of the patient’s allergies, the senior MDT leadership team have not identified that an EpiPen had not been prescribed. Whilst the provider has advised that adrenalin is one of the standard emergency medicines available, patients with known allergies should be individually prescribed an EpiPen.

On Willow ward we found that a patient’s consent to treatment form had not been signed. In addition, we found an unsigned prescription on Willow ward.