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

At our last assessment we rated this key question as requires improvement. We looked for evidence that people were protected from abuse and avoidable harm.

At this assessment the rating has remained as requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

Patients and staff on Silverstone ward told us that bank and agency staff did not always understand patients risks and act in line with their risk management plans. On Silverstone ward, there were some restrictions which were caused by the bedrooms being upstairs and an inability for staff to manage risk across two levels. There were maintenance issues on the wards and ongoing issues with plumbing across the site. These had been raised regularly by staff and patients. The service was actively addressing the issues.

Ward staff, including healthcare workers and registered nurses had not received sufficient specialist training to support the clinical treatment model applied on Silverstone Ward.

The clinic room on Silverstone ward was cluttered and not clean.

The service was in breach of regulations for safe care and treatment, safeguarding and premises and equipment.

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 service mostly had a proactive and positive culture of safety based on openness and honesty, in which concerns about safety were listened to, safety events were investigated and reported thoroughly, and lessons were learned to continually identify and embed good practice.

The provider had a proactive and positive culture of safety, based on openness and honesty.

We saw evidence of 29 safeguarding incidents between 20 December 2024 and 20 March 2025 across the long stay rehabilitation wards, of which 10 were low level concerns and did not meet the threshold for reporting to the local authority, 18 met the threshold for reporting to the local authority and 1 was held as open to determine if it met the threshold.

From the 18 incidents referred to the local authority, 7 were closed and required no further action, 3 of them were being completed as section 42 enquiries by the local authority, 3 were being completed as section 42 by the service and 5 referrals had been made and were awaiting outcomes from the local authority. All of the incidents happened at Silverstone ward. Managers updated ward action plans in response to section 42 enquiry outcomes.

Incidents and complaints were appropriately investigated and reported. Patients and staff were encouraged to raise concerns, and they knew how to report them. We saw evidence of learning from incidents recorded in incident logs and reviewed the Patient Safety Incident Response Framework (PSIRF) Policy. The manager on Silverstone ward told us learning from incidents was carried out by each ward. Daily huddles took place to review the last 24 hours and any critical incidents. Protection plans were put in place for patients where, for example, there was a safeguarding incident. The manager told us the DBT therapist consulted night staff and discussed themes, incidents and provided advice to staff.

Staff understood the duty of candour. They were open and transparent and gave patients and their families a full explanation if and when things went wrong.

The service worked with people and their partners to establish and maintain safe systems of care, in which safety is managed, monitored and assured. The service ensured continuity of care, including when people move between different services.

The service’s referral and admission processes ensured that all essential information about the patient was received to determine if the patient’s needs could safely be met. The manager of Silverstone ward told us patients could visit the ward before committing to and admission. The nurse and DBT therapist or the nurse and RC (Responsible Clinician) would discuss the referral and a DBT therapist was assigned to them prior to admission.

On most wards staff involved all the necessary healthcare and social care services to ensure patients had continuity of safe care, both within the service and post-discharge. The nurses and therapists encouraged home visits, for example during our visit a patient on a delayed discharge was due to visit a placement. Commissioners, care coordinators and family were invited to attend every ward round via online platforms.

A manager told us most patients were discharged back to their local area, but the service was considering developing a DBT step down unit. Discharge planning was initiated on admission. St Andrews Healthcare also had a recovery college (Recovery and Education RED) that patients were engaged with.

The manager on Silverstone ward told us, patients did not always engage in recruitment processes. However, some patients on Silverstone ward had recently expressed an interest and engaged in this. They could share experiences, ask questions and mention all activities that took place on the wards and when outside of the ward such as swimming, going to the gym, having access to education, shopping and going to the zoo. There were plenty of activities and funds to support staff to meet patient needs.

The service mostly worked with people to understand what being safe means to them as well as with our partners on the best way to achieve this. The service concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect, and made sure they shared concerns quickly and appropriately.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff mostly concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider mostly shared concerns quickly and appropriately.

Staff demonstrated a strong understanding of safeguarding and how to take appropriate action. Staff were able to raise safeguarding concerns and ensured they were referred to the local authority.

Staff were trained in safeguarding, knew how to make a safeguarding alert and did that when appropriate. Staff across the long-stay rehabilitation wards had completed their level 3 safeguarding training with a compliance of 96%.

On Silverstone ward we found that staff recorded section 42 outcomes in the ward action log. This included actions to respond to safeguarding concerns raised about the care of an informal patient subject to restrictions on the wards ‘support level framework’. Although some the actions were complete, some had been delayed and timeframes for completion were not always clear.

The provider had effective systems, processes and practices to make sure patients were protected from harassment and discrimination, including those with protected characteristics under the Equality Act 2010. Staff discussed safeguarding concerns at the ward morning huddle meetings, and governance meetings that fed into the divisional meetings. Staff knew how to complete an incident form following an incident and notification or safeguarding referral which were reviewed by management. We saw evidence of this and learning from safeguarding referrals and incidents log as well as the incident report of 2 incidents in detail.

Leaders demonstrated a commitment to taking action to keep people safe from abuse and neglect. This included working with partners in a collaborative way. We saw the safeguarding policy which included what actions to take in such circumstances.

The provider ensured safety for any children visiting the service, with a dedicated area to meet and staff risk assessed any planned visits from children.

During the inspection we observed blanket restrictions and restrictive practice being applied on Silverstone Ward. We found that there was not always a therapeutic or clinical risk need for the application of these restrictions and that least restrictive principle was not always applied.

On arrival to the ward we observed patients sleeping on the floor of the communal areas. We also observed that patients were unable to access a number of side rooms, the upstairs corridors and toilets without having to request support from staff. There were restrictions to patients having access to their bedrooms throughout the day and they had a specific time for when they could go upstairs, dependent on their level on the support framework. However, this was at times applied as a blanket restriction and not implemented in line with the support level framework guidance.

Patients on the ward had raised concerns through the ward community meetings that bedtime and access to their bedrooms was getting later and later. This had not led to a review of blanket restrictions and the implementation of this.

During a focus group discussion with 5 patients, patients told us the ward was very restrictive and punitive in its model. Patients told us that the courtyard was always locked, and most patients could not access their bedrooms during the day. However, during the inspection the courtyard door was unlocked with a door sign stating, courtyard access supervised unless this has been agreed in the ward round and that the door maybe locked to manage risks. Patients told us they had to sleep on the floor in the communal area as they were not allowed to access their bedrooms. Staff told us that one patient laid on the floor of the communal area because the chairs in the communal area hurt their back. They could not lie in their bedroom as there was a restriction on the patient’s bedroom access. Patients also told us and we observed within one care record that they could not access the courtyard (fresh air) for 24 hours following any incident in the courtyard.

During a visit to the ward on the night of 12 March 2025, we found that patients were requesting to go to their bedrooms and ensuites to attend to their personal hygiene and go to bed. Patients and staff told us that access to bedrooms was restricted to after nighttime medicines had been administered and supper provided. Patients and staff told us that patients usually could not access their bedrooms until after 9pm. Staff told us that it was difficult to supervise both levels of the ward and therefore patients could only go up to bed once staff were available to observe and supervise them.

Patients could not freely access side rooms on the ward, including the dining area. There were no hot and cold drinks freely available to patients and patients had to request staff to allow them access to make drinks. Staff told us that hot water had been removed due to recent risks. However, it was unclear in records when this risk was identified, and how the restriction had been reviewed to consider least restrictive practice. The restriction to cold drinks and snacks was not reflected within the ward blanket restrictions log.

The ward’s clinical treatment model and support level framework did not include restrictions on bedroom access outside of the therapeutic day and stated that the therapeutic day finished at 4pm. The support framework outline restrictions on bedroom and side room access but there was limited information on the application of restrictions for all levels of the support framework and the rationale for the specific restrictions.

During a review of the ward action log we noted that concerns had been raised in September 2024 that when newer staff questioned patient’s management plans, staff responded ‘this is what we do here’. A cultural concern had been raised regarding this and some steps had been taken to respond to these concerns. However, we observed occasions where the least restrictive approach was not utilised to respond to individual needs. On 12 March 2025 we observed patients queuing for the toilet in the communal area, as the second toilet was out of service. Some patient’s requested access upstairs to their ensuite toilet and this request was denied without a clear rationale. We also observed a patient becoming distressed and being administered intramuscular PRN medication. The patient remained in the communal area following administration of the medication with a one-to-one supporting staff member. We reviewed an incident report for the same patient later in the day that described the patient requesting to go to their bedroom and this request being denied. The patient attempted to access the upstairs corridor when a night staff member entered the ward and was restrained to prevent this.

We reviewed the ward restrictive practice log and found that this was not reflective of all the restrictions on the ward. We also noted that all blanket restrictions that had been identified were implemented in 2023 and how these had been reviewed was unclear. The ward had identified that there were blanket restrictions for, access to vapes, hot drinks, and access to all areas of the ward. The section of the log that referred to ‘action plan to eliminate or reduce restriction’ all stated ‘not applicable’. Restrictions to access to bedrooms, the dining room and toilet in the day area that we observed, and patients told us about, were not reflected accurately in the restriction log.

Staff and managers told us that restrictive practice and blanket restrictions were discussed weekly in patient community meetings. We reviewed 3 months of community meetings and found that although there was evidence of discussion of blanket restrictions, there was insufficient detail and records to understand the rationale for these restrictions and a lack of plans or actions to eliminate or reduce these restrictions. Restrictions noted included, lack of courtyard access, discussed 6 out of 12 weeks, toilet and courtyard locked off, discussed 2 out of 12 weeks, upstairs corridor locked off, discussed 5 out of 12 weeks. We also found that patients had raised concerns on 3 of the 12 weeks, that access the bedrooms at night time was getting later. The ward manager had provided feedback that he would remind the night staff that bedroom access is discretionary and to ensure medications were completed in a timely manner to enable upstairs access. However, we were concerned that there had been no consideration or action to enable access to bedrooms earlier in the evening and prior to nighttime medicine administration.

On one occasion patients had raised their concern that access to salt and pepper had been restricted for all patients. Patients had expressed that this was unfair. The response to the concerns had been for staff to discuss this restriction in the clinical governance meeting.

Restrictions were also implemented in line with patients’ level of the support framework. The support level framework was referred to in the clinical treatment model but the restrictions for each level were not clearly articulated within the model.

Most patients were subject to a number of restrictions under the support framework. 7 out of 12 patients were on levels 5 and 6 of the framework. This included enhanced or intermittent observations, locked ensuites and bedrooms, supervised access to side rooms, and escorted or supervised courtyard access. There were 3 informal patients on the ward who were not on level 1 of the support framework and were therefore subject to restrictions on bedroom, courtyard, and leave access.

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

Although the use of restrictive interventions was high on Silverstone ward, staff across all wards mostly followed best practice in anticipating, de-escalating and managing challenging behaviour.

Staff completed a risk assessment for each patient when they were admitted and reviewed this regularly, including after any incident. Staff completed a biopsychosocial assessment and formulation of individual risks and developed comprehensive safety plans in response to this. We did see that records contained reference to global risk stratification of low, medium or high when completing risk assessments of self-harm, which was not in line with National Institute for Health and Care Excellence (NICE) guidance.

Most staff knew about any risks to each patient and acted to prevent or reduce risks. However, patients and staff on Silverstone ward told us that bank and agency staff did not always understand patients risks and act in line with their risk management plans. The ward had introduced ‘grabsheets’ that detailed patients’ current risks and care plans to support locum staff to understand and respond to patient risks. We spoke with some bank and agency staff who had a good understanding of the current needs and individual risks for patients.

Staff across all wards completed detailed risk assessment and risk management plans. This included the use of positive behavioural support plans that were developed in collaboration with patients.

Staff identified and responded to any changes in risks to, or posed by, patients. Staff met daily to discuss any changes in risk. Staff also engaged in regular multidisciplinary meetings, safety huddles and staff consults to discuss individual patients risks and developed risk management plans.

Staff regularly completed reviews of risk management plans in collaboration with the MDT and patients.

Staff followed procedures to minimise risks where they could not easily observe patients. Silverstone ward was set across 2 levels and therefore staff were needed to supervise access to the upstairs corridor. Staff told us that this meant that at times they could not allow access to upstairs because staff were busy completing other tasks and supporting patients downstairs.

A few patients across the wards told us that they did not feel safe at night and stated that this was due to a lack of regular staff that understood their needs and risks. Some patients on Silverstone ward also told us, and we saw within community meeting minutes, that there was not always enough female staff to complete their enhanced observations. Patients had raised concerns about being observed by male staff due to previous trauma.

Staff followed provider policies and procedures when they needed to search patients or their bedrooms to keep them safe from harm.

We observed during our visit on 12 March 2025 that some staff were not engaging or interacting with patients while observing them. This included a staff member who was completing one-to-one enhanced observations for a patient. We noted that the staff member did not interact with the patient during enhanced observations prior to her becoming distressed and requiring assistance from more staff.

However, on the other wards there was low levels of restrictive interventions. We were told that the rehabilitation houses were kept locked for all patients. We discussed with managers whether controlled access had been considered in line with national rehabilitation guidance and were told that this had not yet been considered but staff would look into this.

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

We requested environmental risk audits for all wards and were informed that these were not available. A new template had been developed and a blank copy was provided but ward manager training had not yet been carried out for use of this.

Overall, most of the wards were clean and fit for purpose but not all areas were well-maintained and the rehabilitation houses décor was in need of updating. On Silverstone ward, staff and patients expressed that some restrictions were caused by bedrooms being based upstairs and an inability for staff to manage risk across 2 levels. There were maintenance issues on the wards and ongoing issues with plumbing across the site. These had been raised regularly by staff and patients. The service was actively addressing the issues.

Managers across the wards told us that maintenance work was not timely and there was a lack of communication with the clinical team when works had been contracted out. This included no updates on progress and no pre-warning to works being carried out. One manager provided an example of contractors initiating work outside of the ward and not communicating with the ward manager beforehand to enable an environmental risk assessment. Another manager told us that the maintenance logs were updated as ‘completed’ when a contractor was assigned or required and no further progress updates were provided to the ward team.

There was a maintenance request for the conservatory roof leak at Berkeley Lodge, dating back to November 2024 which had not been started. However, the provider informed us that it had been fully repaired by external contractors, but the ticket had not been updated.

On Silverstone ward patients were sharing one communal toilet downstairs because the other was out of order. The ward manager informed us that the plumbing was a significant concern and that maintenance were contacted 3 – 4 times per week due to issues.

Staff knew about any potential ligature anchor points and mitigated the risks to keep patients safe. The organisation completed a ligature risk assessment for each ward. These assessments were reviewed every 12 months.

There was no mixed sex accommodation in the service.

Staff had easy access to alarms and patients had easy access to nurse call systems.

Most clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly. However, the clinic room on Silverstone ward was cluttered and the location of emergency equipment was not easily clear and accessible. This was discussed with ward staff on the day and resolved.

The service 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.

Across all wards staff received and were up to date with their mandatory training. Where levels were low or training was due, there were plans in place to improve compliance.

However, ward staff, including healthcare workers and registered nurses had not received sufficient specialist training to support the clinical treatment model applied on Silverstone ward. The clinical treatment model dated November 2022 identified the following required training for staff, ‘divisional specialist skills training (3 day training), overview of Emotionally Unstable Personality Disorder (EUPD) and DBT (1 day training) and overview of behavioural principles (1 day training).

We were provided the draft of an updated clinical treatment model but this did not contain any training under section 11 which was titled ‘what specific training is required to deliver your clinical treatment model?’.

We noted that within the new clinical treatment models there was reference to training for staff in Reinforce Appropriate Implode Disruptive (RAID) but no records of staff training in relation to this was provided.

The ward did not have a full DBT team, as there were 2 DBT assistant vacant posts, that prior to our visit had not been agreed for recruitment. The entry on the ward action log stated that Human Resources (HR) had declined to advertise for the role due to over recruitment of senior healthcare workers in the division. The clinical treatment model described the process for patient access to DBT skills coaching at part of the therapeutic programme. DBT assistants were expected to be part of the ward team and therefore provide support at weekends and evenings when the DBT therapists were not available. Patients therefore did have access to skills coaching outside of the therapist teams weekday hours.

Following a serious incident in November 2024, an investigation found that some regular staff on the ward had not received sufficient specialist training on the clinical treatment model and support level framework prior the incident. One registered nurse had worked on the ward for 41 days without any training on the clinical treatment model. The staff member did not have experience in the care of females with EUPD diagnosis or informal patients. A deputy ward manager supporting the ward also stated that they had not received training in the support level framework and had only learned through discussions during multidisciplinary meetings. These findings had been added to the ward action log with a plan to restart specialist skills training. However, only an introduction to EUPD and DBT had so far been provided to 13 out of 26 staff. DBT skills and Orientation to DBT had not been provided since 2023 and 2022 respectively. 2 staff on the ward had completed DBT skills training.

A further action from the serious incident investigation was that a DBT awareness pack should be provided to all staff while they awaited more formal 3-day training. This was discussed with the team in January 2025 and planned for discussion at the next staff away day. However, the away day had been cancelled and the awareness pack had not been developed at the time of our visit.

During a patient focus group, 5 patients told us the ward didn’t feel safe due to there not being enough staff, especially at night. A further patient told us that newer staff didn’t appear to have the necessary skills to care for them.

There was a high usage of agency and bank staff on Silverstone ward. From January to March 2025, 47% of shifts had been filled by agency and bank staff. We requested evidence that bank and agency staff had training in the specialist skills needed for the ward and this was not provided. Staff and patients told us that staff that did not regularly work on the ward did not engage patients to support them in line with their care plans. Managers told us that enhanced monitoring of staff to ensure there wasn’t an imbalance of regular and locum staff was needed, but had only recently been agreed by the organisation.

The use of agency and bank staff on the other wards was lower at 23% for Berkeley lodge, 17% for Sitwell ward, 14% for Watkins House, and 13% for Berkeley Close.

There had been high levels of vacancies on Silverstone ward and managers told us that in 2024 they had not been able to recruit healthcare workers, despite having vacancies and high levels of enhanced observations and therefore bank and agency staff usage. Since September 2024 these vacancies and staffing levels had been identified as an issue on the ward action log and a plan was in place to recruit into these vacant positions. The ward manager had also been granted permission to book bank and agency staff ahead of time to ensure staff who were familiar with the ward were booked.

There were vacancies across all wards. The provider told us that the vacancies and staff establishment for Watkins House, 37 Berkeley Close and Berkeley Lodge were not reflective of the current staffing needs. These services had not had a staffing review for 2 years and this had commenced in March 2025. It was expected that due to low occupancy there would be no vacancies following this review. There were 13 healthcare worker, and 1 registered nurse vacancy on Silverstone ward. These vacancies were calculated following an agreement for an extra 7 healthcare workers to be recruited to Silverstone ward.

There were now 2 registered mental health nurses available at night on Silverstone ward and staff told us this had been a recent improvement as previously they were working night shifts without a second qualified staff which impacted on their ability to administer controlled medications and take breaks.

During the night 2 registered mental health nurses worked across Watkins House, Berkeley Lodge and 37 Berkeley Close. They were supported by two healthcare workers on each ward.

Turnover for the last 3 months for all wards was 0.

Staff told us that they were supported through regular and constructive appraisals and supervision. Staff on Silverstone ward also benefitted from weekly staff consult sessions with the DBT team, where they could consider specific cases and apply the DBT model. The ward had recently introduced a night staff consult that took place early morning. Staff stated that this had been a helpful and effective process to enable them to feel more supported and part of the team.

There was adequate medical cover day and night and a doctor could attend the ward quickly in an emergency.

The service did not always assess and manage the risk of infection, detect and control the risk of it spreading. They did share any concerns identified with appropriate agencies promptly.

We reviewed the last 3 months ‘snapshot IPC’ (infection, prevention and control) audits for all wards and these were rated 100% in most areas and above 90% in all areas. However, we also reviewed the infection prevention and control audit reports for Sitwell and Silverstone wards which evidenced overall IPC compliance at 85% for Silverstone and 87% for Sitwell ward. The lowest IPC compliance was in kitchen servery and dining areas. Corrective actions had been identified in response to both audits.

During our inspection, there were no IPC concerns noted on Sitwell ward. On Silverstone ward we found a urine sample in the clinic room with no label, date or name, and the clinic room was visibly unclean, including clinical items that had ‘clean’ stickers on them

The clinic room was also cluttered with items, and inappropriate items were stored on the floor and worktops. There was an overfull clinical waste bin on the floor and it was not possible to access the handwash sink due to clutter around it and used cloths on the side.

Similar concerns had been raised in the infection prevention and control audit carried out by the provider on 25th February 2025.

On Silverstone ward, patients had raised concerns with food temperature on 4 occasions over the last 12 weeks. The ward staff had been reminded of the procedures to ensure the correct temperature of food, but the issue appeared to be ongoing.

The service mostly made sure that medicines and treatments are safe and meet people’s needs, capacities and preferences by enabling them to be involved in planning, including when changes happen.

Staff mostly followed good practice in medicines management (that is, transport, storage, dispensing, administration, medicines reconciliation, recording, disposal, use of covert medication) and did it in line with national guidance. Clean stickers were used but some areas were visibly unclean.

Patients had a good understanding of medicines and side effects. Patients were appropriately involved in decisions about their medicines. One patient at Watkins House stopped smoking and changes to clozapine toxicity levels were considered.

People were involved with assessments and reviews about the level of support they need to manage their medicines safely and to make sure their preferences were included. This was clearly documented in their care plan.

The allergy status was not always clearly identified in the care plan or patient profile, particularly regarding high risk of anaphylaxis. We found a record where the patient’s allergy information on one system did not match the other. While the anaphylaxis risk was recorded, the causative agent was not identified on RIO.

One patient had chronic constipation and was prescribed multiple laxatives. When staff was asked about care plans and how this was managed, they were not able to find them. There was no clear information available to support staff which laxative to give first and properly support the patient to manage their condition.

We observed there were no issues identified with controlled drugs, and stocks were checked regularly. There was an allocated pharmacist to each ward. Stocks were replenished in a rota basis and ad-hoc if required. Medicines audits and CDs audits were completed regularly with outcomes and actions discussed in medication meetings. Pharmacy support was available to each of the wards.