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 for the wards for people with a learning disability and autistic people, we rated this key question as requires improvement. At this assessment we changed our approach, and we now report on most of the wards for people with a learning disability in the forensic ward report as they provide medium or low secure services. At this assessment we continued to rate the wards for people with a learning disability and autistic people not providing secure care as requires improvement.

We found that the wards did not provide safe care. Some aspects of the wards were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed. Environmental risks, including limitations on the environment, were not fully assessed, monitored and mitigated. Staff had not always completed risk assessments for people and updated these regularly. The wards did not have enough regular staff that knew people well to meet people’s needs and anticipate peoples’ distress. Managers had not assured us that staff received appropriate training and appraisal.

The wards was still in breach of legal regulation in relation to people’s safe care and treatment, safeguarding and the deployment of the right numbers and mix of staff with the correct training and skills.

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

We looked at the incidents that had occurred recently at this hospital. All independent hospitals were required to submit notifications of significant incidents to us and to have systems to report and review all incidents including less serious incidents. Between 1 September 2024 and 21 March 2025, the hospital had recorded 4098 incidents across the learning disability and autism division, which included the low and medium secure forensic wards. Most incidents were people who used the service self-harming (1515) or acts of physical aggression hitting other people who used the service (1458). Data was not supplied breaking these down to ward level or to categorise incidents relating to the severity of harm. This meant the way the provider sent the information about overall incidents to us following the inspection, it was not possible to identify which of these reported incidents specifically related to the wards inspected during this assessment.

Systems and processes for staff to record, monitor, and review incidents were not sufficiently robust to consistently identify learning opportunities. For example, we looked at six incidents across the wards including care records and daily notes and associated risk assessments. These lacked detail to enable leaders and the clinical team to effectively review incidents and understand the reasons why an incident occurred. Staff knew how to report incidents but told us that they felt their concerns had not always been listened to in relation to the ongoing risks to staff. The provider's staff injury triage tracker for March 2025 showed that out of 21 incidents listed, 5 related to the wards for people with a learning disability.

Relevant staff were not always completing regular functional analysis to understand fully people's distress, or the antecedents (what happened leading up to the incident) or the wider circumstances to help support people and reduce risks. Staff were not therefore looking in-depth to understand the underlying reasons for people's distress for each incident and over time to consider themes and trends. This meant that staff were not taking opportunities to fully understand the function of people's distress and support them in better ways. This also meant learning opportunities to review and reduce risks to people were often missed. The corresponding spreadsheet relating to serious and STEIS reported incidents showed 2 incident. These had a description of each incident and actions and these did not give detail to understand these incidents fully either.

One person in the supported transition service managed to be involved in a serious incident while on 3-to-1 observation.

There were no visible leadership strategies or commissioned audits to address and reduce the numbers of self-harming incidents for the two people in the separate transition services.

Leaders had a system and process for staff and people to attend de-brief sessions so they could discuss incidents and reflect upon any learning. Staff we spoke with stated that when incidents occurred, they were not always given the opportunity to reflect through debriefs. The provider requires that debriefs should also be documented within the patient's progress notes, but the provider noted that they have identified inconsistencies in this practice. Care records corresponding with some incidents did not evidence a debrief had occurred. Therefore leaders missed opportunities to ensure lessons were learnt following significant incidents and to aim to reduce the risk of similar incidents reoccurring.

The provider did not always work well with people and healthcare partners to 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, including when people moved between different services.

People were not positive about their experience of planning for discharge. People had come up against barriers in the process of discharge, though it was not clear if this was from staff at the hospital, or with services in the community.

Clinical leaders had started to draft and develop systems and governance processes in place to support safe admissions, discharges and transfers of care but these were not fully developed or embedded. The wards had a model of care which included some high level principles underpinning the model. The hospital was working to develop the supported transition services and had hospital and social care supported transition services (STS). This draft model of care described ‘Our STS are designed to enable a person to successfully move to the community in the shortest time period. Development of a community package of care in partnership with commissioners and community support teams is essential, and a non-negotiable expectation, from the outset.’

It went on to state ‘Our STS are designed to meet the specific complex needs of the person. The services are not predicated on specific diagnoses or specific risk profiles.’ The model of care did not reference national policy about reducing the numbers of people with a learning disability and autistic people who are segregated from other people (as considered by Baroness Hollins’ most recent report). The progress towards a community package of care and the steps needed were not developed well on the records we saw. Staff had not looked at the 12-step discharge process to assess what progress had been made towards discharge and address any barriers. The 12-step discharge process is prescribed by NHS England to ensure that people with a learning disability and autistic people are discharged from hospital as quickly as possible. The draft model of care did not provide detail about the admission and exclusion criteria for admission.

Staff sought comprehensive information about people as part of their pre-admission assessment. This information was discussed within the multidisciplinary team, so that they could ensure they were able to meet the needs of the person. However, in one case we saw that the environment of the unit was not fully suited to the person’s needs to manage risks and information relating to ongoing incidents were not fully considered to review the suitability of the placement following the initial assessment.

Staff worked collaboratively with each other to promote joined-up care. However, staff did not always work effectively with external stakeholders to ensure transitions between services were managed well. For example, staff had not identified people in the supported transition services as being eligible for an independent care (education) and treatment review. One person had been allocated a senior intervenor in recognition of the complexity of the care and that more needed to be done to progress the person’s care.

Each patient’s discharge was discussed throughout their stay on the ward, and staff worked with representatives from the patient’s home care team towards this.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always 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.

One person reported that they had raised a safeguarding alert against a member of staff alleging they had pulled their hair. Another person reported they had been subject to inappropriate restraint. Staff were aware of these incidents and they were being investigated.

The provider had a safeguarding policy and processes for tracking the progress of safeguarding referrals. Over the six-month period from 1 September 2024 to 21 March 2025, the learning disability and autism division reported that there were 65 safeguarding's recorded on the incident reporting system that were referred to the Local Authority. Of these 5 related to the people on Glendale and Billing Lodge. These were all open to the local authority safeguarding team and had not been concluded. Four related to self-harm incidents when people were on high levels of observations and 1 related to physical violence and aggression. The allegations made by patients to us were not detailed in the data.

When incidents occurred, leaders could view CCTV in communal areas to look into the allegations. However, there was no CCTV in some areas including in people's bedrooms for their own privacy. We looked to review incidents involving restraints through checking CCTV footage, following our review of incidents and feedback given to us by people u. However the incidents occurred in the areas that did not have CCTV so we were unable to check.

Staff we spoke with knew how to recognise adults and children at risk of or suffering harm and abuse and could explain what they would do about it. At the provider's safeguarding audit from December 2024, in relation to staff from the learning disability and autism division, 75% of respondents confirmed they felt confident in recognising a safeguarding incident following the recent changes in the thresholds for safeguarding,

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.

People told us about incidents of restraint where they felt staff had not used correct techniques. People had raised concerns about these episodes of restraint, and these were already known to the hospital and were being looked into.

One person recognised they struggled with their distress but commented that staff “don’t know how to respond to me most of the time.”

Staff completed risk assessments for each person on admission using a recognised risk assessment tool. However, staff were not always updating risk assessments immediately after significant incidents. Risk assessments showed ongoing episodes of restraint and seclusion. Incidents showed similar incidents occurring in short succession with a similar or escalating pattern which may have been better predicted if incidents had been analysed.

People worked with staff to create their positive behavioural support (PBS) plans. These plans help people to manage their distress and help guide staff on useful and supportive strategies. However, PBS plans reviewed did not fully meet national guidance.

The plans could have had clearer primary preventative strategies which focused on improvement of quality of life and ensuring needs are met. The 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. The plans were not informed by full and proper functional analysis to understand the fuller circumstances of people’s behaviour and the underlying function of people’s distress. There was a lack of individual prescribed safe holds for staff to use to ensure they were the least restrictive option.

Records showed that for one person there had been a significant number of incidents with 150 incidents over six months and 3 out of 6 months having over 30 incidents. Incidents were considered in terms of type and number of incidents but there was very limited information to better understand the antecedents to these incidents and learn more about the functions of the person’s distress.

The staff we spoke with did not all know the contents of the PBS plans or did not have full access to electronic records. This included one nurse in charge we spoke with. One bank nurse told us that this was their first shift working with the person. They had not had an opportunity to review the person’s care plan. PBS plan or one page profile – they were only relying on information provided at handover.

The provider did not always detect and control potential risks due to the layout of the care environment when restraint was required. However ongoing maintenance of equipment, facilities and technology supported the delivery of safe care

The environment of each of the wards had been developed around the needs of the people in the service but they were not fully safe. The environment of Billing Lodge had been developed around the needs of one person. However, the environment was not fully appropriate and was not fully safe. This was because the person presented with specific risks and the environment did not mitigate these risks. These included narrow corridors, the ward being over 2 levels with a narrow staircase with no lift and doors that did not swing both ways. This meant that there was not sufficient space for the person to be restrained and moved if required. The person had an unplanned move to a different environment on another ward as a result.

The units were clean and tidy, and the décor generally well maintained. There had been attention to ligature risks. The provider had a maintenance log. These showed a small number of minor maintenance jobs on Glendale and Lime Trees Cottage. There were no reported maintenance jobs for Billing Lodge on the system. Billing Lodge was recently refurbished around the needs of one person but the person was temporarily cared for on a different ward. People had access to a suite of rooms and an area to access fresh air.

Staff knew the processes and procedure in place for reporting potential risks in the care environment. Staff were aware of environmental risk assessments, including ligature risks.

People who used the wards did not comment favourably on their environments. Their comments included that ‘the environment here is shit and old’. People also commented on the sparseness of their environments and the personal items that had been removed from them as being disproportionate.

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

Each person was on enhanced observations and supported by more staff to manage and mitigate risks. However, regularly people were supported by bank or agency staff that did not know them well. This was often due to staff sickness levels. People we spoke with reported that agency and bank staff did not interact with them well as they did not always know their needs or preferences.

Staff sickness rates were high. The average sickness level between September 2024 and February 2025 for the learning disability directorate was 10.1%. In relation to the specific 3 wards for this report, staff sickness was over 10% for 3 out of 6 months for Billing Lodge and Glendale; and 2 out of 6 months on Lime Trees Cottage. The highest sickness rate was Glendale in February where 21% of staff were off sick in February 2025 and 19% in January 2025. These figures were well above the national average sickness levels for mental health and learning disability services in the NHS which was reported between 5.5% and 6.2% for the months September 2024 to February 2025 (according to national published benchmarking data). Leaders had added high levels of sickness on the risk register for the learning disability and autism directorate. The provider had detailed some control measures in place to mitigate current sickness levels including delivery of recruitment and weekly meetings with human resources (HR).

Regular staff were not fully supported and trained to interact with autistic people. Staff we spoke with told us that they had received limited training on how to interact with autistic people and a learning disability which included a short session on induction and e-learning. Staff reported to us that they would benefit from further more in-depth, specialist face to face training on understanding autism to support them to care for people in better ways. The hospital’s risk register identified that there was a lack of more specialist training for staff in interacting with people with a learning disabilities and autistic people staff across the learning disabilities and autism service division. The provider had rated this as a moderate risk. Leaders told us that they were looking at their training in light of the forthcoming Oliver McGowan Code of Practice. This statutory code aims to ensure that staff working at all levels across the health and social care sectors receive high quality and appropriate training on learning disability and autism.

Staff had completed and kept up to date with their mandatory training. Overall, staff compliance with mandatory training across the learning disability and autism directorate was at 96%. The quality matron reported that they recognized that staff required more specific training in relation to autism and trauma informed practice. This was being rolled out on some forensic wards for people with a learning disability and autistic people already. The directorate also planned for 5 staff to be trained as trainers to deliver SPELL which stands for Structure, Positive (approaches and expectations), Empathy, Low arousal and Links. SPELL was the National Autistic Society’s framework for understanding and responding to the needs of autistic children and adults. It focused on five principles that have been identified as vital elements of good practice when working with autistic people, and emphasised ways to change the environment and approaches to meet the specific needs of each person. Leaders said National Autism Society accreditation had been achieved on other wards across the hospital.

Leaders said the senior leadership team have recognised that the traditional staffing establishment tool used by the hospital has not been fit for purpose for these specialist wards. They recognised that more staff and effort to improve people’s access to activities and occupation including more staff to facilitate 'leave'. Leaders of the wards told us this had been accepted by the senior leadership team who had agreed to increasing the staffing numbers on each shift.

The wards for people with a learning disability and autistic people had low staff turnover rate. This was recorded on a monthly basis and was running at 0% for much of the last 6 months up to February 2025. The exception was a one-off 13% turnover rate for Lime Trees Cottage and 5% for Billing Lodge in October 2024.

Many staff were not receiving an appraisal of their work. The overall staff appraisal uptake rate across the 3 supported transition services was variable. Information from the provider showed that, as of 18 April 2024, none of the 17 staff at Glendale had received an appraisal; uptake at Lime Trees Cottage was 72% and no figures were provided for staff appraisal uptake levels at Billing Lodge. This meant staff supported people with complex needs, but not all staff had an opportunity to discuss their work, to receive feedback and look at developing their skills.

Managers recognised and were open about the challenges that staff faced due to the acuity and presentations of some of the people. Some staff reported they did not always feel fully supported when facing staffing challenges and had not had proper debriefs following incidents.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

No concerns were raised by people about infection prevention and control.

The environment of the units were generally clean and well maintained. However, they were stark as many items had been personal items that had been removed from peoples room due to risk. People had access to their own en-suite toilet and shower areas.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

People were involved with assessments and reviews about the level of support they needed to manage their medicines safely and to make sure their preferences were included. Staff had created visual information for one person to help them understand their medicines.

There was an allocated pharmacist to each ward at St Andrews Healthcare Northampton. Stocks were replenished in a rota basis and ad-hoc if required. Staff completed medicines audits and controlled drug audits were completed regularly with outcomes and actions discussed in medication meetings. Pharmacy support was available to ward teams where required to improve the ward’s practice relating to medicines. Staff at Billing Lodge were using the clinic room on Church ward to store one person’s medicines as the person was segregated on that ward. The clinic room was found tidy and not overstocked.

People’s medicines were appropriately prescribed, supplied and administered in line with the relevant legislation. Consultant psychiatrists regularly reviewed people’s consent to treatment status to ensure that medicines were properly authorised under the Mental Health Act. The prescriptions on the electronic record matched the authorisation form from a second opinion appointed doctor and antipsychotics prescribed were within guideline limits specified by the British National Formulary. The BNF is a reference book which provides guidance on each medicine, including the recommended maximum dosage. The doctor had a good understanding of STOMP principles and reviewed medicines in light of this. STOMP is an initiative which aims to stop the over medication of people with a learning disability, autism or both).

New staff could not begin work at the hospital until training was completed which included face-to-face sessions, coursebooks, and e-learning. Agency staff were required to complete e-learning training and undergo an induction on their first day to assess competencies. Refresher training and reflective exercises were also required as a result of medication incidents.