- Independent mental health service
St Andrews Healthcare Northampton
We have taken urgent enforcement action by imposing a condition on St Andrew's Healthcare's registration on 14 July 2025 to keep service users safe by restricting new admissions at St Andrew's Healthcare Northampton. We have also imposed a number of conditions on St Andrew's Healthcare registration on 10 November 2025 to require the provider to make improvements in the safety and quality of care provided relating to; staffing, ward environments, blanket restrictions, risk management, observations, incident management, governance and systems and processes.
Assessment report published 12 December 2025
Contents
Ratings - Forensic inpatient or secure wards
Our view of the service
Overall Summary
This assessment of forensic inpatient or secure wards at St Andrew’s Healthcare Northampton took place between 11 July and 13 August 2025. This was an unannounced focused inspection which was carried out in response to a serious incident of concern. The incident (which took place in June 2025), took place on a learning disability/autism ward (LD/A). The incident resulted in staff injury. The incident was identified by the provider. Managers completed a review of the incident, including viewing the incident on closed circuit television (CCTV) on 1 July 2025. Upon review of the incident via CCTV, the provider identified several serious concerns regarding the management of the incident, and inappropriate use of safe intervention techniques (SIT). The provider then took immediate steps to safeguard the patient and take the appropriate action regarding the staff members involved. The incident raised questions in relation to people’s safety, alleged inappropriate use of restraint, alleged staff assault on the person and a lack of privacy and dignity. The incident also raised concerns about a closed culture within the organisation.
St Andrew’s Healthcare Northampton is part of St Andrew’s Healthcare, which is a registered charity. The charity provides specialist mental healthcare for patients who may have complex presentations, with challenging mental health needs. During our inspection we visited wards across the medium secure, low secure, child and adolescent (CAMHS) and learning disability/autism services (LD/A) wards.
An inspection has been undertaken of a specialist service that is used by autistic people or people with a learning disability. We have assessed the service against ‘right support, right care, right culture’ guidance to make judgements about whether the provider guaranteed people with a learning disability and autistic people respect, equality, dignity, choices, independence and good access to local communities that most people take for granted.
During our inspection, we visited the following wards as part of the assessment:
Brook ward: a low secure ward for persons diagnosed with a major mental illness, Learning Disability and/ or Autism for men with 10 beds
Oak ward: a recovery-orientated medium secure service for women aged over 18 with 10 beds
Bracken ward: a blended forensic admissions Ward for women with 11 beds
Fairbairn ward: a medium secure service for deaf men with 17 beds within the medium secure and learning disability/autism services (LD/A) wards. In addition, we reviewed 12 patient records, 26 incidents from across the forensic services (including medium and low secure, LD/A) and CAMHS ward via review of CCTV, spoke to 14 staff and undertook observations on 3 wards.
During the inspection we inspected 5 quality statements under 3 key lines of enquiry safe and caring, and 4 quality statements under well-led.
We found evidence of a hospital wide closed culture resulting in improper and abusive treatment of people and patients. We took urgent enforcement action to impose a condition on the provider’s registration to restrict new admissions across the entire location.
We rated the service as Inadequate.
The provider was previously in breach of the legal Regulations of safe care and treatment, safeguarding, good governance, and staffing. Improvements were not found at this inspection, and the provider remained in breach of these regulations.
The provider was also found to be in breach of the legal Regulation of dignity and respect.
In instances where CQC has begun a process of regulatory action, we may publish this information on our website after any representations and/or appeals have been concluded, if the action has been taken forward.
This service remains in special measures. The purpose of special measures is to ensure that services providing inadequate care make significant improvements. Special measures provide a framework within which we user our enforcement powers in response to inadequate care and provide a timeframe within which providers must improve the quality of the care they provide.
Mental Health Act and Mental Capacity Act Compliance
Most patients were detained for treatment under the Mental Health Act 1983.
Staff stored copies of patients’ detention papers and associated records within the electronic health record. Staff could access them when needed.
Patients had access to an Independent Mental Health Advocate (IMHA). Posters were displayed on noticeboards on the wards with contact details to reach this service. However, the contract for providing advocacy services had recently changed. We were informed that contact with the new advocacy service had to be requested via an appointment system. We were concerned that the new arrangements for advocacy could have an adverse effect on patients being able to obtain independent advocacy support in a timely manner.
Due to staffing levels, staff were not always able to ensure that patients could take section 17 leave (permission to leave the hospital) when this was agreed by the multidisciplinary (MDT) team.
Staff explained to each patient their rights under the Mental Health Act. Rights were repeated to patients as required and this was recorded in patient records. Patients were provided with leaflets, and these were available in a different formats or languages if required. Patients told us they were informed of their rights.
Staff had access to support and advice on implementing the Mental Health Act and its Code of Practice. Staff could access support from the provider’s Mental Health Act administration department.
Staff received and kept up to date with training on the Mental Health Act, this was mandatory for staff.
The service had relevant and up-to-date policies and procedures that reflected all relevant legislation and the Mental Health Act Code of Practice.
Mental Capacity Act
Staff generally had a good understanding of the Mental Capacity Act, in particular the five statutory principles
The provider had a policy on the Mental Capacity Act, including deprivation of liberty safeguards. Staff were aware of the policy and had access to it. Staff knew where to get advice from within the provider regarding the Mental Capacity Act, including deprivation of liberty safeguards.
Staff took all practical steps to enable patients to make their own decisions. For patients who might have impaired mental capacity, staff had assessed and recorded capacity to consent appropriately. They did this on a decision-specific basis with regard to significant decisions.
When patients lacked capacity, staff made decisions in their best interests, recognising the importance of the person’s wishes, feelings, culture and history. The service had arrangements to monitor adherence to the Mental Capacity Act.
On the child and adolescent mental health ward, staff considered Gillick competence (a test in medical law to decide whether a child of 16 years or younger is competent to consent to medical examination or treatment).
People’s experience of the service
During our inspection, we spoke to 7 patients (4 patients on Fairbairn and 3 patients on Brook ward). On Fairbairn Ward, 4 patients raised concerns regarding the lack of effective communication between staff and patients on the ward. Two of the four patients on Fairbairn ward told us that they felt “unheard”. One of the patients described feelings of “despair and isolation”, another patient spoke of “extreme loneliness, pain and lack of engagement from staff”.
Patients on Fairbairn ward told us of numerous consequences of ineffective communication. One patient raised frustration with staff, particularly around facial expressions and non-verbal cues, which they told us they found triggering. Another patient told us they had been falsely accused of aggression; they told us they felt misunderstood due to the lack of staff awareness of deaf culture and facial expressions. Concerns from patients on Fairbairn included allegations of “ongoing racial abuse from other patients”, which patients claimed were being ignored by staff members and management.
People on Brook ward were mostly positive about their care and treatment. However, one person told us that bank staff “grab your wrist”. The same person spoke to us about concerns relating to swearing on the ward and that there had been violence on the ward (for example a television had been smashed by a patient).
People's experience of this service
During our inspection, we spoke to 7 patients (4 patients on Fairbairn and 3 patients on Brook ward). On Fairbairn Ward, 4 patients raised concerns regarding the lack of effective communication between staff and patients on the ward. Two of the four patients on Fairbairn ward told us that they felt “unheard”. One of the patients described feelings of “despair and isolation”, another patient spoke of “extreme loneliness, pain and lack of engagement from staff”.
Patients on Fairbairn ward told us of numerous consequences of ineffective communication. One patient raised frustration with staff, particularly around facial expressions and non-verbal cues, which they told us they found triggering. Another patient told us they had been falsely accused of aggression; they told us they felt misunderstood due to the lack of staff awareness of deaf culture and facial expressions. Concerns from patients on Fairbairn included allegations of “ongoing racial abuse from other patients”, which patients claimed were being ignored by staff members and management.
People on Brook ward were mostly positive about their care and treatment. However, one person told us that bank staff “grab your wrist”. The same person spoke to us about concerns relating to swearing on the ward and that there had been violence on the ward (for example a television had been smashed by a patient).