Archived: St Andrews Healthcare Northampton

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; promoted an open, fair culture.

During this inspection we considered how people were receiving services in line with Right Support, Right Care, Right Culture. At the last inspection of LDA services, we rated this key question requires improvement. This rating has changed to inadequate. At the last inspection of forensic inpatient/secure and CAMHS wards, we rated this key question good. At this inspection the rating changed to inadequate. This mean that there were widespread and significant shortfalls in service leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

We have not awarded this service a score for Well-led.

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

The provider did not have a shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities.

During our inspection, several staff told us that leaders did not appreciate and understand the challenges that staff were facing. Numerous staff members told us their concerns (raised with managers), had been ignored or not taken seriously by leaders.

The service had a shared strategy and values in place, which was to relieve suffering, give hope and promote recovery. The service aimed to achieve this by ‘focusing on 6 core areas.’ The core areas focused on the quality of care, delivering value, buildings and information, people, new partnerships and innovation and research.

The service also had 4 core values. These were compassion, accountability, respect and excellence. However, most staff we spoke with did not understand the strategic direction of the hospital and how these related to the delivery of care. This concern has been identified during recent inspections of the hospital.

Most staff were not positive the vision of the service or the therapies and services which had been introduced. The provider commissioned a ‘Your Voice survey, with data collected between 3 to 24 June 2024. The outcome of this survey showed that one of the five bottom scores across all services, related to the question if ‘new therapies and services introduced by St Andrew's closely match what our patients/service users want’. The mean average score to this question across all services, was that only 44% of staff had a positive response. The lowest response to this question was across the 2 low secure wards, where the mean average score was 29% of staff showing a favourable response.

The provider had identified that one of its core values was excellence. However, most staff told us that due to current staffing levels, they were not always able to provide an excellent service. The provision of adequately skilled staff was a theme across the wards. For example, in the medium secure clinical governance meeting (January 2025), staff reported that they had been ‘raising the need for a higher proportion of regular staff since May 2024’. In addition, staff at the LDA clinical governance meeting (January 2025), had reported concerns (on numerous occasions), regarding the hours that the RC (Responsible Clinician) was allocated to Berry ward and the provision of Occupational Therapy. It is also recorded that ‘this was also raised as part of NHS Wales (commissioner’s) feedback’.

The provider focused on equality and diversity and the training levels for staff were above 94%. However, during our inspection some patients and staff told us that they had been exposed to episodes of racial discrimination. Incident reports, interviews and a review of patient records further confirmed that racist incidents against patients had taken place.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.

Following our previous inspections of LDA wards (April 2024), medium secure wards (October 2024) and CAMHS (November 2024), unsafe staffing levels were identified. The findings of this inspection did not provide us with assurance that sufficient systems and processes were in place to address these concerns. Nor were we assured that systems were sustained and embedded to ensure safe staffing levels delivered safe care and treatment. Apart from the 2 low secure wards, Spencer North and Spencer South, we found that staffing numbers had not been adequately reviewed and analysed to ensure they met patient needs. This resulted in high levels of non-permanent staff working on the wards. There was a lack of oversight and response from senior managers to identify and escalate issues with safe staffing. This meant there had not been sufficient improvement to assess, monitor and improve the quality and safety of the services provided.

Staff told us that the ‘bleep holder’ would regularly have to move staff to other wards to fill gaps in staffing, without first checking the acuity of the wards. It was also noted that the bleep holder did not check the skills and competencies of the staff members before moving them to different wards.

Staff have told us how difficult it was being open with senior leaders. Staff described a disconnect with senior management, adding that “they don’t know what is going on”. This includes a lack of presence of senior leaders on the wards, senior leaders not listening and or accepting the clinical risks being described and a focus on numbers and not qualitative data.

Many staff told us that there is no point in speaking up, as senior leaders were defensive and would not listen to concerns. Staff reported that senior leaders appear not to be accepting of the clinical risks some patients and staff were facing and experiencing. Staff told us that they had continuously raised concerns about staffing levels and patient risk, however they had not been listened to. Therefore, patients and staff were being put at risk. We were informed that there was a lack of support from managers regarding incidents. Consequently, staff were being assaulted. We were also informed that unnecessary restrictions were being put in place. For example, patients had been placed on higher levels of enhanced observations, than were generally required. This was because many staff did not have effective skills and competencies in relation to effective risk management strategies.

The result of the Your Voice Survey (June 2024) reflected our findings from inspection. The results showed that most staff were not favourable about the support they received from managers. For example, only 36% of staff (mean average across all services) felt positive about leadership and communication. The lowest percentage score (20%) was from staff on low secure wards. The mean average response from staff who were favourable about ‘senior managers acting on staff feedback’ was 24% The lowest percentage score was 7%, from staff on Acorn Ward/Garden Cottage). In addition, the mean average of staff across all wards who were favourable about ‘communication between senior management and staff was 31%, with the lowest favourable response (7%), from staff on Acorn Ward/Garden Cottage).

Staff informed us that some patients had to remain in seclusion and extra care due to a lack of staff to effectively safely maintain patients on the ward. We were told of one patient who was not receiving access to fresh air, despite this being approved in the patient’s care plan.

Staff must feel safe to raise concerns on the wards, particularly in a medium secure unit. These concerns must be actively considered by the senior leaders and escalated to the board. The risk of harm to staff must be a serious consideration with patients who have a history of serious offences (including serious assaults and/or murder) including those patients who are on a life tariff.

Numerous staff members spoke with us about the closure of Sycamore ward, which had led to the transfer of some patients to Oak ward. We were told that there had been a lack of consultation with staff. This had resulted in an increase of acuity on the ward. This was confirmed on the day of our visit, when every patient on Oak ward was on enhanced observations. Documents reviewed across the service refer to staff burn out and high levels of incidents on this ward.

Ward staff were told that ward managers and bleep holders were available on a day-to-day basis to support with ward dynamics and any staffing issues. However, we heard that decisions were often made to take staff off wards, without the manager or bleep holder being aware of any potential issues on the ward. Ward managers said that the senior leaders across the division were easily accessible and approachable.

People did not feel they could speak up and that their voice would be heard. We received mixed feedback on the leadership and culture of the service. Numerous staff members told us that they did not feel comfortable speaking up. Staff told us that senior leaders had been defensive and would not take concerns seriously. The mean average of staff (across all services), from the My Voice Survey, who felt comfortable speaking out was 52%, with only 21% of staff on Hawkin’s ward feeling favourable about speaking up.

Whilst the hospital operated a ‘Safe call’ system, (a confidential service where staff can report complaints or concerns, without fear of perceived retaliation), the number of concerns raised by staff were low. We reviewed concerns raised through this process across all wards. Between 19 September 2024 and 13 February 2025, staff had raised 5 concerns across medium secure wards. Concerns included unfair treatment towards a peer (no evidence to support), and a staff concern. Three further concerns related to staff being asleep on duty. One had been closed, with no evidence, and two remained under investigation at the time of our inspection.

There was one concern raised from the low secure wards, and staff on Seacole had raised 2 issues in relation to a serious incident during this period. Managers had advised staff members of the process which would be undertaken in response to the incident. In January 2025, staff from the medium secure wards had raised 2 concerns. One related to alleged breach of policy, which was not substantiated, the other related to allegations of unfair treatment and racism, which was under investigation.

We spoke with several staff on Meadow ward, who had been raising concerns about staffing levels for some time. Staff had been experiencing difficulties making sure they were able to facilitate patients’ leave and take their entitled breaks. The staff we spoke with felt unheard by the senior leadership team.

When something had gone wrong, people had received a sincere and timely apology and were told about any actions taken to prevent the same happening again. We spoke with senior leaders regarding some concerns following the review of CCTV. The team were actively discussing how to be open and honest with the person involved, while minimising any further distress to them.

The provider did not value diversity in their workforce. They did not work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The provider told us that the service worked towards an inclusive and fair culture by improving equality and equity for people who worked there. However, not all staff felt that there was a fair culture within the organisation. Some staff spoke to us about racism toward both patients and staff. We noted that 2 concerns raised via the provider’s safe call system, contained allegations of racism toward staff.

Staff spoke to us about being physically assaulted by patients and a lack of associated actions by the provider. One staff member told us that the provider does not take attacks on staff seriously and that there is no support post incident. We reviewed the minutes of the medium secure divisional governance meeting for held on 4 March 2025. The record of this meeting shows that ‘multiple staff assaulted multiple times and then had to go back onto patient observations and were unable to go home’.

The ’My Voice’ survey also showed that staff did not always feel recognised for their work, within only 52% of staff (overall mean average) feeling positive about the recognition they received. In addition, only 32% of staff across all wards (mean average), felt that they were satisfied with the extent that the provider values their work.

The service had relevant policies and processes in place to enable leaders to take ongoing action to continually review and improve the culture of the organisation, in the context of equality, diversity and inclusion.

The hospital had recognition and appreciation awards in place for staff, which staff appreciated. The service had several Charity networks to promote inclusivity such as WiSH, BAME, DAWN, PRIDE and Unity. The provider told us at the time of the inspection, there were no reported incidents of racial abuse. Staff were encouraged to speak up and were aware of their right to report to the police and access the support available within the charity.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

We were told that staff felt a lack of support from senior leaders. Staff told us how difficult it was being open with senior leaders. In the My Voice survey only 31% of staff across all wards (mean average) felt that the communication between senior management and staff was effective. Staff on most wards told us that they had continuously raised concerns about staffing levels and patient risk, however they had not been listened to. We were told that staff above ward level would only focus on quantitative information (for example in the form of key performance indicators) and would not listen to qualitative information provided by staff in relation to patient risks and poor standards of care. Staff told us that there was no point raising concerns as nothing changes.

Leaders were aware of the risks of a closed culture. For example, leaders had arranged for specific training and support on Rose ward following an incident, when staff were aware of a concern, but this hadn’t been shared. However, managers did not appear to be aware of all the indicators (inherent risk factors and warning signs), which are outlined in line with guidance. Consequenly leaders were not addressing risk factors. For example, we found a lack of openness and transparency between managers and staff. We also found evidence that a range of warning signs had not been addressed. For example, we were told that staff were not supported or encouraged to raise concerns and that some staff had been actively discouraged and were afraid to 'speak out'. We also found that there had been allegations of staff bullying, some staff worked long hours and overtime (in line with working time regulations), and there were concerns about the condition and suitability of the physical environment that people are living in, which are not being adequately addressed in a timely way.

Five members of staff across the medium and low secure wards reported that senior leaders appeared not be accepting of the clinical risks some patients and staff were facing and experiencing. Many have said that there was no point in speaking up as senior leaders were defensive and would not listen to concerns. This could further promote a closed culture. However, staff on Spencer South told us that staffing had improved and that the ward was ‘rarely’ short staffed. Staff must feel safe to raise concerns on the wards, particularly in a medium secure unit. These concerns must be actively considered by the senior leaders and escalated to the board. The risk of harm to staff must be a serious consideration with patients who have a history of serious offences (including serious assaults and/or murder), who are on a life tariff.

We identified ongoing issues with staffing numbers, skill mix, a lack of specialised training for staff, as well as a lack of continuity of staff on some wards. This had impacted negatively on people using the service. Staff have informed us that as a result staff are being assaulted, unnecessary restrictions were being put in place (as many staff do not have effective skills and competencies in relation to effective risk management strategies), and there was an increase in restrictive practices. 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 ward.

We did not feel that staff were adequately trained to work on specialist wards. For example, for Fairbairn ward (which is advertised on the provider’s website as the largest UK medium secure service for deaf men), we found that there were inadequate levels of staff on the wards who were BSL trained. We reviewed staffing over the ward over 90 days and found that during that period over 50 % of staff were not BSL trained. Consequently, staff were experiencing difficulties with communication. This had led to frustration and incidents. However, staff told us that more BSL training was being arranged for later in the year.

In addition, staff had not received specialist training for working with patients with autism. The provider had a plan in place for staff to receive SPELL training (the National Autistic Society’s framework for understanding and responding to the needs of autistic people). However, a the time of our inspection, across the LDA division, only a total of 12 staff out of 396 had completed this training, equating to just 3%.

We did not feel assured that people using the service had been appropriately protected from harm following onsite activities undertaken, which involved speaking to people using the service, speaking with staff, and observing some episodes of care and treatment. We also reviewed related documentation, to include care plans, PBS plans, day to day clinical notes, incident forms and safeguarding referrals made to the local authority.

There were systems and processes in place to monitor and review the quality of the service. Different senior staff had responsibility for overseeing certain areas of the service. However, we did not find this to be effective. Several staff members told us that concerns they had raised within a clinical governance meeting had not been taken seriously and acted upon. For example, in the medium secure clinical governance meeting dated 13 January 2025, it was recorded that ‘There is a large number of gaps in OT (occupational therapy) and TI’s (technical instructor) provision. Recruitment justifications for gaps went to the panel before Christmas, but it was reviewed only today. Triumvirate (the management team) have escalated this as it leads to unacceptable delays in replacing critical staff.

Maintenance issues had not always been identified and acted upon, despite senior staff undertaking regular audits of the ward environments.

We found that some restrictions placed upon people had caused frustrations, were not robustly clinically justified to use as a blanket approach, nor were they always the least restrictive option.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

The service worked with other agencies including commissioners, health and social care professionals, police, the local authority safeguarding team and the Ministry of Justice. The provider told us that external partners are invited to Care Programme Approach (CPA) meetings. Staff also provide regular updates to external regarding the patient’s progress. The provider worked with a range of other agencies to focus on service improvement.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. The services were engaging in 22 research programmes, most of which were provider led, one in collaboration with a university and one with another provider.

The provider had systems and processes in place for reviewing quality. However, the provider had not ensured that learning from the quality improvement opportunities (including external reviews and internal audits/visits) had taken place. For example, in January 2024, the commissioners had raised concerns relating to blanket restrictions in relation to food and lack of access to cold drinks independently. We were concerned about the number of blanket restrictions on the wards, 14 months after concerns were raised by commissioners. In April, May, August, November 2024, February 2025 concerns were raised regarding staff not being bare below the elbow, which is a concern we found during our inspection. In January 2025 during an environmental audit concerns were identified on Willow and Robinson wards, in relation to patient fridges not being clean and food items not being labelled/ use by dates. During our inspection we identified several concerns regarding the cleanliness of fridges and the storage of food.

The provider had a range of continuous quality improvement initiatives (CQI) in progress. For example, across the low secure and CAMHS wards there was a CQI project in place which aimed to address the lack of meaningful activities on the wards. The project background acknowledges that the wards had ‘experienced a lack of numbers in occupational therapists and technical instructors, which had an impact to activities offered to patients. The review of progress to date showed an incremental increase in the number of nursing led activities from zero in February, March and April to 13.6 in January 2025. Whilst this is an improvement, the number of hours remain significantly lower than the 25 hours of meaningful activities which the provider is required to achieve. In addition, the project outline does not mention the significant pressure already faced by nursing staff on the wards, and the associated increased pressure that this project would place on nursing staff.

The service had a focus on continuous learning, innovation and improvement. The hospital is part of strategic and clinical improvement networks. These include IMPACT (East Midlands Provider Collaborative for Adult Secure Care), REACH OUT (West Midlands Provider Collaborative for Adult Secure Care) and the East Midland's Alliance for Mental Health, Learning Disabilities and Autism.

The three wards we visited, described as wards for autistic people (Acorn, Berry and Meadow) had received the National Autistic Society (NAS) Autism Accreditation in 2024.