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. At our last assessment we rated this key question good. At this assessment the rating has changed to inadequate.

Inadequate: This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation 12 in relation to safe care and treatment, regulation 13 safeguarding service users from abuse and improper treatment and regulation 18 staffing.

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. Lessons were not learnt to continually identify and embed good practice.

Ward representatives and multidisciplinary team members attended daily risk management (divisional huddle) meetings (Monday to Friday). Incidents, areas of concern, staffing and complaints occurring in the previous 24 hours were discussed so that lessons could be learned, and any known shortfalls could be escalated and planned for. However, we were concerned some risks were not being effectively managed because not enough action was taken in response to known risk and repeated incidents.

For example, 1 patient had several falls in the period from December 2024 to March 2025. During our inspection we saw this patient walking around the ward area disorientated and unsupervised. They had been assessed as requiring intermittent observations (every 15 minutes) during the day. We asked for assurances regarding action taken in response to these incidents. We were told the level of enhanced intermittent observation was safe. When we visited the ward again on 9 April 2025 we were informed their observation level had been increased to constant observation (one to one) to keep them safe. There was delay in the provider learning lessons from reported incidents and taking appropriate action such as increasing observation levels sooner to prevent further falls and risk behaviour.

There was closed circuit television (CCTV) in operation in communal areas across all 3 wards. Leaders did not routinely review the CCTV footage following incidents. We reviewed CCTV of an incident where a patient fell and hit their head and reviewed the CCTV. We saw that staff were not following the provider’s policies for enhanced observation. Following our review, the provider commenced an investigation. However, not routinely reviewing CCTV following incidents in communal areas was a missed opportunity for the provider and staff to learn lessons and improve safety.

Monthly divisional governance and ward governance meetings took place and meeting minutes referred to incidents and complaints but there was a lack of detail, analyses or any clear action plan for learning lessons or improving safety.

We requested data regarding incident analyses meetings for incidents occurring in the 3-month period January to March 2025. We were told these meetings did not take place and there had only been 1 incident in within this time. Patients records reviewed showed this was inaccurate. We saw there had been numerous reported incidents during this time. These included, falls, incidents of aggression between patients and incidents of aggression from patients to staff. This highlights the missed opportunity to learn from incidents and improve safety at the service and a lack of manager oversight and review.

The provider had a patient safety incident response policy (PSIRF). This policy sets out the provider’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents and issues for the purpose of learning and improving patient safety. Staff we spoke with understood their responsibilities to report incidents and were able to explain the reporting procedures and systems including how they would apply ‘duty of candour’ when things went wrong. However, we were not assured these incidents were being effectively analysed by senior staff.

There was a hospital wide bi-monthly lessons learned group meeting. The provider told us lessons learned were shared at daily huddles, sent to staff via e mail and discussed at staff meetings. We were provided with examples of lessons learned information shared with staff. However, there was minimal reference to lessons learned being discussed within team meeting minutes across all 3 wards for staff meetings in December 2024 and January and February 2025.

Staff told us they had access to debriefs following incidents but these were not routinely taking place. The psychology team offered ‘reflective practice’ to staff on a weekly or as required basis either face to face or on-line. However, staff did not always have time to attend these sessions.

The provider did not always establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care.

There was a lack continuity of care because of the high use of agency and bank staff who did not know the ward or fully understand the patient’s needs.

We found that staff did not always follow the providers policy for enhanced observations. There was a high number of observations recorded late, and this meant we could not be sure they had taken place at the required time. The provider’s systems were not effective for identifying the concerns we found with late observations across all 3 wards. Safety was not a priority, and systems did not flag the number of late observations to leaders so risk could be identified and addressed.

The risk assessment used for ligature risks on the ward was flawed because it did not take into account the dynamic/changing needs and risks of patients on the wards and had not identified all potential ligature points on the wards. This meant staff may not be aware of these risks or how to ensure patients safety. All patients across all 3 wards were identified as medium or low risk. We were not assured all patients had been correctly risk assessed because some patients had complex mental health needs and should have been identified as high risk (Patients with acute severe mental illness and/or depression, chaotic behaviours). The risk assessment recorded ‘good observation’ as a control measure and compensatory factor to manage the risk. However, systems and processes for enhanced observations were not always effective so this was not an effective mitigation.

Patient’s relatives told us staff involved them and supported them with their transition into the service. They told us staff discussed future regarding moving on from the service during multi-disciplinary reviews.

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 always share concerns quickly and appropriately.

The provider had a ‘safeguarding vulnerable adults and children policy’. Staff we spoke with understood their responsibilities to identify and report abuse and had received training in level 1 and 2 safeguarding children and adults. Compliance with this training was above 89% across all 3 wards. However, safeguarding incidents and concerns continued to occur and not enough action was taken to protect patients from abuse of improper treatment. Patients were not always protected from each other or from risk behaviour, in particular when receiving personal care or during episodes of distress. For example, following review by the multidisciplinary team (MDT), physical abuse caused to a patient by another patient was recorded as not meeting the threshold for a safeguarding referral and the level of harm caused recorded as ‘no harm’ despite this being a physical assault.

Concerns regarding staff following the provider’s enhanced observation policy were ongoing at the time of this inspection. We were not assured the risk of abuse was sufficiently managed. The recording of enhanced observations carried out were frequently late as described in the ‘safe systems and pathways’ quality statement section of this report’. We could not be assured these observations had been carried out or that patients were protected from abuse and improper treatment because of the frequent late recording.

Data provided about safeguarding incidents from 18 December 2024 to 18 March 2025 recorded 10 safeguarding incidents, 6 did not meet the threshold for external reporting. However, we looked at 12 patient records across the 3 wards and saw not all incidents of abuse were included within this data. For example, incidents not recorded in this data included; a patient found to have a wound with no known cause, missed positional changes for a patient with known pressure sore risk with resulting observed skin damage, a patient having frequent falls, a patient with significant weight loss and a patient displaying distressed behaviour resulting in aggression to staff resulting in restraint being used and physical assaults on staff.

We reviewed ward meeting minutes, clinical governance and divisional governance meetings for December 2024 to February 2025 and found safeguarding was not always on the agenda or was recorded as ‘to be confirmed’, or there was minimal discussion or action plans for known safeguarding concerns. We were not assured staff always identified and reported all incidents of potential abuse or that leaders had sufficient oversight of incidents and potential abuse occurring on all 3 wards.

Patients and relatives, we spoke with said they felt safe and had no current concerns. However, while people expressed general satisfaction, we found elements of care did not meet the expected standards as described above.

Staff had received training about restrictive practice and restraint known as ‘safety intervention training. Compliance with this training was above 87% across all 3 wards. Staff we spoke with understood their responsibilities to comply with these policies and acts. However, some restrictions where being applied across all 3 wards without appropriate consideration or rational. For example, all 3 wards used only plastic cutlery, this may not suit all patients needs and in particular patients who had been on the wards for several years and no risk had been identified. Restrictions should be individualised and included within care plans.

The provider had a ‘least restrictive practice policy’ dated November 2024 to promote the reduction of restrictive practices. This policy stated restrictions should only be applied for the shortest possible time. A patient had restrictions applied for accessing snacks. This restriction was not supported with any best interest decision or nutrition care plan. Another patient was restricted to the amount of alcohol they could consume each day. Again, there was no best interest or rationale for this restriction recorded. As well as this, a patient had restrictions imposed upon them as a result of an incident they had been involved in. This was against the provider’s policy. The provider’s policy stated that restrictions should ‘never be used for punishment or other non- therapeutic purpose.’ The policy also stated restrictions should only be used for the shortest possible time. We were concerned there was not always a therapeutic or clinical risk need for the application of these restrictions and that the least restrictive principle was not always applied. These blanket restrictions may be degrading for patients, some of whom had been on the wards for several years.

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.

Each patient had their individual risks assessed on admission and reviewed during weekly care coordinator meetings. Risk assessments included physical risks such as pressure sores, falls and swallowing difficulties and psychological risks such as aggression and other risk behaviours. Each patient had a care plan about keeping safe, however these did not always include all known risks and did not always provide enough detailed information about what actions staff should take to keep patients and others safe.

A patient we case tracked was below a healthy body weight and a known risk of malnutrition and dehydration had been identified. Though staff had completed risk assessments and contacted the dietetic team for support, there was a failure to take action to manage the risk. Records showed this patient was consuming insufficient amounts of food and fluid frequently. There was no care plan for eating and drinking for staff to follow. No evidence of food and fluids the patient was known to prefer being offered or food and fluid being offered outside of normal mealtimes. We sought assurances regarding this lack of risk management but despite this, the patient continued to lose weight and was admitted to hospital. Not enough action was taken to reduce the risk of harm.

Another patient’s records showed they had not met their daily fluid target for 7 out of 13 days reviewed, but there was no evidence action had been taken in response to this so the risk could be safely managed. There was a lack of effective risk management for another patient known to be at risk of falling and frequently falling as described within the quality statement ‘learning culture’.

We were also concerned about the frequent late recording of observations because we could not be assured the required observations had been carried out in line with the provider’s policy. We looked at observation records from January to March 2025 for 3 patients and found a high number of late recorded observations. For the patient at risk of falling, observations were recorded late 72% of the time. This meant patients may not be protected from known risks.

Some patients displayed verbal and physical aggression to others and to staff . Not enough action was taken to manage these risks. For example, 1 patient was frequently injuring staff. A solution had been identified where staff were to be provided with protective equipment for their arms, but this had not yet been implemented at the time of our inspection, so staff had sustained cuts and scratches on their hands and arms. Systems and processes were not always effective to ensure debriefs with staff and patients were completed in a timely and effective way after an incident had occurred, so that action could be taken to reduce further risk and improve quality of life.

The provider had a risk register to monitor known risks. However, we found risks were ongoing and not sufficiently managed or that risks had not been identified.

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

We found several unmanaged risks in the environment posing a risk to patients, many of whom were independently mobile and moving around the ward area unsupervised or with minimal supervision. On Aspen ward on 12 March and 9 April 2025 the communal bathroom was unlocked and contained patient’s personal hygiene products and creams which patients could access and accidentally ingest. Latex gloves were stored in the corridor and accessible to patients and were a ‘swallowing/choking risk’. A storeroom on Elm ward containing furniture, incontinence products, gloves and a hoist was found to be unlocked and accessible to patients on 2 occasions during our visit on 11 March 2025.

On Cherry Ward on 11 March 2025, we observed 2 small personal alarms were on a shelf on the main corridor and accessible to patients presenting another swallowing/choking risk. We also found a cupboard containing substances hazardous to health unlocked. This posed a risk to patients and should be locked at all times.

There were several ligature risks on all 3 wards within unlocked bathrooms and bedrooms. In particular, wardrobes, metal fixings for wall padding and clothes hangers. However, staff told us ligature risk was low for the patient group. There was a ligature ‘heat map’ which highlighted ligature risks on the ward. On Aspen ward bedrooms were on a long corridor which allowed visibility for staff to monitor patients but there were 2 bedrooms on a separate corridor creating a blind spot and there were no visibility mirrors to mitigate risk. We were not assured ligature risks had been fully assessed or mitigated for each individual patient. Ligature cutters were stored in a locked cupboard which staff had access to, however, on Elm ward, staff had signed and dated the checks on a ‘post it note’ so it was not clear what had been checked.

The provider carried out annual ligature risk assessments on each ward. The ligature risk assessment completed in January 2025 for all 3 wards recorded risks for ligature points in the environment as low or medium with mitigating factors such as doors being locked and every patient being checked at least hourly. However, we found the storeroom door unlocked on Elm ward and bathrooms unlocked on Aspen ward on 2 occasions and were not assured staff always followed the providers enhanced observation policies so therefore these risks were not always effectively mitigated.

None of the patients across all 3 wards had been assessed as high risk within the ligature risk assessments. However, we were not assured this was accurate for all patients, particularly on Aspen ward which is an admission ward so the patient’s needs may not be fully understood by staff. This ligature risk assessment included individual suicide risk the use of which are known to be flawed because suicidal impulses are highly changeable and can change within minutes. The use of risk assessments for suicide is against current best practice guidance provided by the National Institute for Health and Clinical Excellence published September 2022.

The provider did not make sure there were enough skilled and experienced staff because there was a high reliance on non-permanent staff. They did not work together well to provide safe care that met people’s individual needs.

The required staffing establishment was calculated using a staffing tool. However, because of an ongoing need for some patients who required enhanced observations and additional staff (some patients required a 1 to 1 or 2 to 1 staffing ratio to keep them safe) the wards used bank and agency staff to fulfil this requirement. The provider told us there was only 1 staff vacancy (registered nurse) across all 3 wards.

Staff received induction training when they first began employment as well as ongoing training. Data provided for staff training across all 3 wards showed that compliance with mandatory training was high (Elm 95%, Cherry 96% and Aspen 98%). Training data was recorded as mandatory and non-mandatory. Compliance with non-mandatory training was lower on Aspen and Cherry wards. Compliance with this training on Aspen ward was low at 63%. As well as this the high usage of bank and agency staff meant that skill mix was not always appropriate to ensure patients received consistently safe, good quality care that meets their needs, also taking into consideration skill development, people’s aspirations and potential. For example, staff training compliance about dysphagia (swallowing difficulties and choking risk) was above 93% across all 3 wards but not all agency staff had received this training. This was concerning due to the high dysphagia risks identified on these wards.

Not all staff had the required skills and experience to meet patient’s needs. Staffing numbers had improved due to recent and ongoing recruitment and staffing numbers were met or were above required numbers for each shift. However, there was a high reliance on bank and agency staff and staff from other wards working overtime. This meant there were few permanent staff on duty who knew and understood patient’s needs. Many staff reported this as a concern. A staff member said, “Patients just won’t work with unfamiliar staff”. Another staff member told us agency staff did not know the patients or understand their needs such as the best way to approach and provide reassurance. This patient group had high personal care needs and required a consistent staff group who knew how to manage their resistance and distress. This was a known concern and had been recorded within governance meetings for December 2024 and January 2025. These records stated, ‘mostly agency staff covering who have little or no knowledge of patient needs’ and ‘allegations of abuse and continuous verbal and physical aggression towards staff have created low morale and emotional distress and remains ongoing.’ These issues were ongoing at the time of our inspection in March and April 2025.

The total number of WTE hours worked across the 3 older people’s wards (Elm, Cherry and Aspen) over a 3-month period from 18 December 2024 to 18 March 2025 was 4,574 of which 51% were worked by permanent staff. The remaining 49% were covered by non permanent staff: agency (13%), workchoice (19%) and overtime (17%)

The high use of bank and agency staff was recorded as a high risk on the provider’s risk register as follows; ‘Increase in enhanced support in the past 4-5 months due to complex physical and mental health needs of existing and newly admitted patients has led to utilise bank and agency staff; and as a result staff are unfamiliar with patient group and this has resulted in increase in incidents and safeguarding concerns.’ Actions to resolve and manage this risk were not effective because these concerns were ongoing.

At nighttime there was only 1 qualified nurse on Elm and Aspen wards making it difficult for them to take breaks, leave the ward or administer controlled medicines (this requires 2 qualified medicines trained staff). Qualified staff had to take their breaks on the ward and could not leave unless the nighttime bleep holder (manager) was able to relieve them. We were told a second qualified nurse had recently been introduced to work nights on Cherry ward to support the administration of controlled medicines across all 3 wards, but they were often too busy to leave Cherry ward in order to support Elm and Aspen wards. A patient told us they frequently had to wait for pain relief because the nurse was not available. Following this assessment, the provider told us a procedure for 'single nurse' administration was in place for staff to use when a second nurse was not available. However, at the time of this assessment, staff we spoke with were not aware of, or using this process.

There was a team of occupational therapists and therapy assistants, psychologists and psychology assistants. However, their availability to support therapeutic activities was limited because there not enough of them to meet the needs of patients on all 3 wards. Vacancies in the social work team (the social work team were a centralised divisional team) meant there was no allocated social worker for wards and this meant they did not always attend multidisciplinary meetings and this may have resulted in delay for patients requiring social work support and intervention. The provider told us there was 1 staff vacancy for occupational therapy and none for psychology at the time of this assessment

Staff sickness rates across all 3 wards for a 3-month period (December 2024 to February 2025) were slightly above the national average (7.9%). Staff turnover for the same period was low (1.4%).

Two patients told us there were not enough staff and a lot of agency staff and 1 relative said there were less staff than there used to be.

There were no concerns identified or reported regarding medical staff. Each ward had an allocated responsible clinician (psychiatrist). Physical health doctors were part of the wider hospital team and could be requested as required. Out of hours medical cover was covered using a rota system. Staff told us the relationship with medical staff was good and they were accessible in a timely way. One patient told us there were at times, delays in the doctor coming to see them when they requested this.

Staff were recruited in a safe way. Required checks and references were obtained before employment was offered to ensure as far as possible, only staff with the right skills and experience were employed.

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 looked at communal areas including bathrooms and some bedrooms on all 3 wards. Separate housekeeping staff were responsible for cleaning and followed schedules and checklists about how different areas and equipment should be cleaned, these included daily and weekly cleaning schedules and deep cleans. Annual in-depth infection prevention and control (IPC) audits were carried out as well as monthly snapshot audits. All 3 wards had scored 100% in their most recent audits. However, we found areas on Aspen and Cherry which were not visibly clean.

On Aspen ward, we saw a visibly dirty toilet, a stained mattress cover and pressure cushion, used and soiled tissues on a hand basin and in a jug in a communal bathroom. We also saw patients own toiletries and wash clothes in communal bathrooms on Aspen and Cherry wards and this poses a risk of cross infection if used by other patients. The provider took immediate action to rectify these issues when we pointed them out.

On Cherry ward we saw stained flooring and a visibly dirty toilet. The water in the fish tank in the dining area on Cherry ward was dark green and did not appear to have been cleaned for some time and we did not see a cleaning schedule for this task.

Each ward had a courtyard providing outside space for patient use. The flooring in the courtyards on Cherry and Aspen wards were visibly dirty. The ward manager told us the flooring in Cherry ward courtyard was due to be cleaned. Some of the outdoor furniture was stained. There was green and damp staining to the walls in the Aspen ward courtyard.

We were not assured patients were protected from the risk of infection or that leaders had effective oversight of IPC on Aspen and Cherry wards.

Patients and relatives told us they found the wards clean and tidy. Elm ward was visibly clean in all areas we looked at.

The provider had an infection prevention and control policy. Staff received trained in hand hygiene and IPC annually. Training compliance for IPC was 81% or above on all 3 wards. Staff we spoke with were aware of their responsibilities for effective hand hygiene and infection control. We saw an agency nurse on Elm ward was wearing jewellery which was against best practice and the provider's policy for IPC. The ward manager took immediate action to address this.

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.

There were concerns regarding how covert medication (administering medicines in a disguised form) was managed and communicated. Information was shared via email rather than patient records and administration records did not clearly indicate that medications should be given covertly. Staff relied on their knowledge to administer these medications safely. When asked, staff were not able to show us a covert administration plan for the patient. Care plans and administration records should accurately reflect patient needs. On discussion with the ward Consultant, they agreed this information needed to be accessible and we were assured all patients receiving covert medicines would be reviewed.

Time critical medicines were given on time with times displayed on a whiteboard in the clinic room to support staff.

Patients receiving Olanzapine depot (medicine used to treat schizophrenia and bi polar disorder) are required to be observed for 3 hours post injection. We saw records of observations done appropriately, however they were recorded under different sections within patient notes which made these records hard to find. By the end of the day, the ward Consultant had created and shared with staff a monitoring form so records could be kept all in one place and of easier access. We also saw displayed on a whiteboard in the clinic room, a guidance on how to monitor patients’ post-olanzapine depot, as a reminder for staff.

The providers electronic system for managing patient’s medicines was unavailable during the morning of our inspection visit (11 March 2025). This caused some delays and pressure on staff to start the morning medicine round. However, contingency plan allowed for medicine administration records to be printed, including medicines administered in the last 24 hours, to support staff administer medicines safely. The system was overall very slow.

Diabetes waswell-managed with clear care plans. Blood glucose monitoring (BMs) were done as per the care plan, with escalation and responses handled appropriately.

The provider had a policy which covered all aspects of the safe management of medicines, and this included the training delivered to staff responsible for managing medicines. Staff were required to complete initial training and ongoing training and competency assessments to ensure their practice was safe.

Appropriate action was taken in the event of a medicine error, this included recording an incident and seeking advice and or review by a medical professional.

The provider employed pharmacists who supported the ward and carried out checks and audits to promote safety and compliance with best practice. A pharmacy Technician or Assistant visited the wards at least every two weeks to provide a topping up service for medicines supply. They also completed clinic room audits every 6 months and controlled drug audits every 3 months. Audit information, detailing any areas of where wards had not achieved 100% compliance, was shared with the ward clinical teams for their review and action.

We observed medicines were stored securely and administration records were accurate and up to date.

Staff and 1 patient reported concerns about delays in administering controlled medicines at nighttime on Aspen and Elm wards because there was only 1 qualified nurse, and 2 qualified nurses are required for the administration and recording of these medicines.