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. During this inspection we reviewed how patients were receiving services in relation to incidents of restraint, self-harm and harm from others. The provider was previously in breach of the legal Regulations of safe care and treatment, safeguarding, and staffing. Improvements were not found at this inspection, and the provider remained in breach of these regulations. During this inspection we also found the provider to be in breach of the legal Regulation relating to dignity and respect.

At our previous inspection of forensic services (medium and low secure, and LD/A) and the CAMHS ward, we rated this key question inadequate. At this inspection the rating has remained inadequate. This meant people were not safe and were at risk of avoidable harm.

The provider was previously in breach of the legal Regulations in relation to safe care and treatment (Regulation 12), safeguarding (Regulation 13), and staffing (Regulation 18). Improvements were not found at this inspection, and the provider remained in breach of these Regulations.

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 evidence showed significant shortfalls. The service did not have a proactive and positive culture of safety based on openness and honesty. They 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.

The service did not have a proactive and positive culture of safety based on openness and honesty. This inspection was triggered due to a serious incident on the ward. When we spoke with staff, several staff told us managers had not informed them of the incident which had taken place. This was a serious incident which involved 17 staff members. Two staff members told us they were aware of the incident because of “talk between staff”, not because it or the learning from the incident was shared by managers. This incident raised immediate concerns regarding the lack of staff care and treatment of people. Whilst it is accepted that investigations were underway (and issues relating to individual staff members had to stay confidential), the identified concerns regarding unacceptable care and treatment should have been communicated to all staff immediately.

Two staff members spoke to us about the closed culture on the wards. One staff member spoke about the adverse effect on staff of the provider trying to save money. Another staff member told us that “everything felt paused”, adding that staff received no positive feedback. The staff member also spoke about the impact of managers (above ward managers) working from home and how this had made managers inaccessible. Staff therefore did not have daily access to managers in person if required, which left staff feeling unsupported. However, the provider has told us that staff can access a range of managers over a 24 hour period. This includes ward managers, general manager, quality matron, associate director of nursing, service director and the bleep holder.

The provider shared details of the process in place for sharing learning. This included the daily ward huddles, lessons learnt bulletins and clinical governance forums. The provider shared details of lessons learnt posters which had been circulated to all wards. Managers advised that lessons learnt are initially shared via email for the whole division and then are cascaded through the divisions via central governance routes (such as quality huddles and quality safety groups) and discussed in staff meeting on wards. This could be confirmed on viewing minutes of team and service meetings.

Whilst processes were in place for the distribution of learning, we did not observe evidence of any audit in place to assess the effectiveness of the processes of sharing information. In addition, the current process for sharing learning did not appear to have adequately taken account of the need for effective communication with temporary staff. For example, 3 staff members we spoke with told us that learning had not been shared with bank staff. However, the provider had a system in place for the communication and distribution of patient safety notices, which included a return form for leaders to confirm that they had the opportunity to discuss the risk and that appropriate actions would be taken.

When we spoke with staff members, they were able to tell us what incidents they should report and how to report them. However, our review of patient records evidenced that staff had not reported all incidents. During our review we identified 8 incidents for which a corresponding incident report had not been raised. The provider conducted reviews between 8 July and 11 August 2025. A review of these incidents identified that 21 incidents across forensic wards had been incorrectly reported. In addition, we identified 4 incidents which had not been recorded within the patients’ notes by staff members.

The evidence showed significant shortfalls. The service did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services.

The service did not adequately monitor patients’ safety. Staff had not always protected patients from harm. During our inspection, we identified several incidents of alleged patient abuse, and inappropriate use of restraint techniques which had led to patient harm. Between 11 July and end of August 2025, the CQC received 7 allegations of assault by staff on patients including allegations of physical assaults, sexual assault, and financial abuse. Concerns included inappropriate patient restraints on 3 wards, and a staff assault of a patient on a further ward. We also reviewed allegations of patient injury during restraint and 2 allegations of intimidation/bullying by a staff member.

Our review of people’s records on Brook and Oak ward identified concerns regarding 1 alleged staff assault on a patient, 2 allegations of financial abuse (2 patients), 3 allegations of abuse by staff, 2 allegations of threats to patients by staff (including death threats) and concerns that staff were talking about the patient.

Following the serious incident on one ward, CQC required the provider to take steps to address concerns regarding to people’s safety and closed culture. Action being undertaken included conducting patient and carer safety interviews, reviewing CCTV footage of all incidents involving restraint, speaking to staff and providing additional closed culture training. The provider has also sought external support with a hospital wide culture review.

The provider shared information in relation to formal complaints, including details of a formal complaint on Acorn ward. This complaint was regarding a person’s discharge from the service, the late referral to the local community mental health services, and limited access to unescorted and community leave. Concerns regarding the person’s discharge plans were also raised by the regional commissioners who referred to “significant delays in referring the person to the local mental health team” and concerns that “the majority of actions outlined in his care package within his CTR document hadn't been implemented”.

The evidence showed significant shortfalls. The service 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. They did not share concerns quickly and appropriately.

Staff had not always concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. Over 90% of staff had received training in safeguarding and staff told us they knew how to make a safeguarding alert. However, we found staff had not always raised a safeguarding alert when required. During our review of patient records, we found 6 incidents where a safeguarding referral had not been made when a referral had been required. In one case of an alleged abuse by a staff member, staff had recorded that the alleged incident “did not meet the threshold” for referral to the Local Authority. In addition, as part of our review of people’s records, we reviewed documented allegations of financial abuse on Brook ward.

During the period 1 May to 25 August 2025 across the forensic wards, 114 safeguarding incidents were referred to the Local Authority. The highest number of referrals related to incidents of self-harm (28), allegations of abuse by staff to patients (27), incidents of physical violence and aggression (26) and security incidents (9). Of the 114 safeguarding referrals, 65 had been recorded as low or no harm, 48 were graded as moderate harm and one was rated as major harm. As of end of August 2025, 32 of the referrals were closed at referral stage and 36 referrals met the section threshold for section 42 enquiry. Section 42 (1) of the Care Act 2014 sets out the criteria that must be considered in relation to raising a safeguarding concern, and the subsequent decision as to whether a safeguarding enquiry is triggered. Of the 36 safeguarding enquiries 20 were being undertaken by the provider and 16 are being conducted by the Local Authorities’ safeguarding team.

All wards had a restrictive practice log in place, which contained a list of restrictive items. Whilst some restrictions were identified as needing to be individually risk assessed, wards also had lists of blanket restrictions. Whilst we note that the restrictive practice log was reviewed monthly, there are several restrictions which are applied to the ward not to individual people. Blanket restrictions should be avoided unless they can be justified as necessary and proportionate responses. To evidence this, the restrictions would need to be individually assessed. However, staff had recorded in the minutes of the low secure clinical governance meeting (June 2025), that “it was agreed that blanket restrictions should be standardised across all low secure wards”.

Staff had not always protected patients from abuse and harm. During this inspection, we reviewed 26 incidents via CCTV which involved inappropriate restraints, staff assaults on patients and a lack of appropriate care and treatment. The provider conducted reviews between 8 July and 11 August 2025. Review of these incidents identified that during this timeframe, there had been 10 incidents of inappropriate restraint and 10 patient injuries across the forensic wards.

We reviewed a serious incident which had taken place on a ward in June 2025. The incident involved an episode of restraint resulting in the person being secluded. On review of the incident, we saw the restraint was unsafe, disproportionate and placed the person at risk of serious harm, including risk to life. We saw several unacceptable and abusive actions from staff which included approaching the person in what appeared to be a combative (confrontational) manner, restricting the person’s airway, kicking the person, striking them in the face with an open hand and pushing the person forcibly.

A staff member involved in the incident could be seen smiling as well as looking at the CCTV camera.

None of the staff members involved took action to safeguard the person. None of the staff members involved raised any concerns about the management of this restraint and obvious serious risk faced by the person. The fact that staff members had not raised any concern in relation to the incident together with the fact that staff had attended the incident from wards and divisions other than the one where the incident occurred, was indicative of a closed culture across the organisation. A closed culture is a poor culture that can lead to harm, including human rights breaches such as abuse.

During our inspection we reviewed 26 further incidents on CCTV. Of the 26 incidents we were able to view, 12 incidents identified concerns regarding the care and treatment of patients (6 of which were high level concerns). Concerns identified included one incident where staff members used inappropriate restraint techniques (involving staff leaning on patient’s joints and pushing a patient forward by placing pressure on a patient’s back), we observed a further incident where a staff member obstructing a patient’s airway and staff members were observed dragging a patient into seclusion.

The review of CCTV also showed a further incident of a staff member assaulting another patient, in addition to the incident referred to above.

The evidence showed significant shortfalls. The service did not work well with people to understand and manage risks. They did not provide care to meet people’s needs that was safe and supportive.

Patients had not always been protected from harm. Staff had not always used appropriate restraint techniques. During our inspection we reviewed 15 patient records. This included a review of daily progress notes, risk assessment and risk management plans, physical healthcare (including body maps) and incidents (including incident reports). During our review of patient records, we identified 2 incidents of staff restraining patients in the prone position. A prone restraint is a type of physical restraint, holding a person chest down, whether the patient placed themselves in this position or not, is resistive or not and whether the person is face down or has their face to the side. The first patient had been restrained in the prone position for less than one minute. A second patient had been restrained twice in the prone position. One for the duration of less than one minute, and the second for 3 minutes.

According to figures shared by the provider, there had been 90 prone restraints across the forensic wards in the 6-month period between 1 February and the end of July 2025. However, the provider has advised that one third of all prone restraints are immediately moved away from prone restraint, and approximately one third of all prone restraints are moved away from prone within 1 minute. Of the remaining 1/3 of all prone restraints moved after a minute, most have been moved away from this position by 5 minutes with only 3 prone restraints that were longer than this. The average duration of a prone restraint if it lasted more than a minute was around 5.5 minutes. The maximum length of prone restraint recorded was 75 minutes

The Code of practice: Mental Health Act 1983 states that “unless there are cogent reasons for doing so, there must be no planned or intentional restraint of a person in a prone position”. This is because the use of prone restraint has been identified as a contributory factor in several deaths in the NHS and police custody.

During our review of one patient’s records, details of an incident on Bracken ward were noted. Following the incident, staff reported that the patient had a large bruise on their right arm and reported that the patient was distressed after the incident. The patient received a post-incident debrief, and the Positive Behaviour Support (PBS) plan was updated to reflect learning from the event.

During our review of another patient’s record on one ward, we noted that a patient had made allegations of abuse by staff. Staff had recorded details of the allegations in the patient’s records, however there were no details recorded of any actions being undertaken. Despite the allegation of abuse by staff, it had been recorded in the patient’s records that the incident “did not meet the criteria for referral to the Local Authorities’ safeguarding team”. Review of the same patient’s records evidenced that the patient had later raised concerns with a nurse, stating that it had felt “like staff were on her back” during a restraint. As part of our inspection, we reviewed this incident on CCTV. During the incident 2 staff members could be observed pushing the patient forward into the prone position, to enable staff to administer intramuscular medication. Staff could be observed pushing and retaining pressure on the patient’s back throughout the restraint. This was not a taught restraint technique and staff were at risk of causing an injury to the patient’s back.

Patients had also provided feedback via formal complaints. Between 1 June and August 2025, the provider had received 21 complaints, of which the highest number (15) related to staff attitude and behaviour (12 related to conduct, one treatment of a patient, 1 of abuse/verbal aggression and 1 allegation of sexual assault by a staff member). Three complaints related to issues which had been initially raised by CQC. Two staff members told us patients had reported that staff members had been asleep during their shift.

Staff ensured that patients could access advocacy. 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.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

The evidence showed significant shortfalls. 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.

The service did not make sure there were enough qualified, skilled, and experienced staff. For example, at the time of our inspection on Oak ward, there was a total of 7 patients, out of which 4 patients were on 2 to 1 observation (requiring 8 staff), and 1 patient in the extra care area requiring support from 5 staff. Thirteen staff members were required to cover observations and there were 13 staff on the ward. This left no available staff member to support the additional 2 patients on the ward or carry out any additional duties required. Based on the current nursing model, there were 13.4 vacancies across the service. However, the number of nursing staff required to meet the needs of the patients, were higher than the funded establishment allowed per shift.

The ward managers could adjust staffing levels daily to take account of case mix. When necessary, managers deployed agency and bank nursing staff to maintain safe staffing levels. Review of figures shared by the provider, showed that between 1 May and 25 August 2025, across all wards, a substantial proportion of shifts were filled by agency, bank or overtime staff. This indicated ongoing staffing challenges.

On the medium secure wards 6,757 additional shifts (37% of all shifts) were covered by temporary staff. Agency shifts ranged from 13% on Bracken ward to 1.7% on Robinson ward. Bank shifts were as follows: 20% (Cranford) to 2.5% (Maple). Overtime: 20% (Mackaness to 13.6% (Willow).

On the learning disability and autism wards 9,195 additional shifts (40% of all shifts) were covered by temporary staff. Agency shifts ranged from 19% on Oak ward to 1% on Berry ward. Bank shifts were as follows: 23% (Sunley) to 5% (Fern). Overtime: 22% (Acorn), to 11% (Marsh.

On the low secure wards, 843 additional shits (34% of all shifts), were covered by temporary staff. Agency shifts were less than 1% on both Spencer North and Spencer South. Bank shifts ranged from 10% on Spencer South to 7% on Spencer North. The percentage of overtime for both wards was around 8%.

On Seacole ward (CAMHS), 2,333.63 additional shifts (57 % of all shifts) were covered by temporary staff. Agency shifts covered 28%, bank 20% and overtime 8% of all shifts.

The high reliance on temporary staff was having an impact on the continuity of care and was impacting on staff morale. Staff shortages had resulted in staff cancelling escorted leave or ward activities. Two staff members told us that patient leave was sometimes cancelled due to staffing levels. One staff member told us of a day on Marsh ward, when an incident left staff unable to provide people with their dinner. Another staff member told us that qualified staff cannot take a break during a night shift. During a community meeting on Acorn ward in August 2025, a person raised concerns that activities were not always taking place.

There was a shortage in the number of permanent medical staff, however gaps were filled with locum doctors. The number of consultant forensic psychiatrist vacancies were identified as a risk on the service’s risk register. We were told there was adequate medical cover day and night, and a doctor could attend the ward quickly in an emergency. However, we reviewed documentation relating to an incident on Oak ward where there was a delay in medical staff undertaking a review of a person’s seclusion. In addition, staff were unable to terminate the person’s seclusion, when it had been deemed appropriate to do so. This was due to inadequate staffing levels on the ward at the time, to facilitate the required 2 to 1 patient observation required post seclusion. The provider advised that at the time of this decision, the ward had 9 observations and was 5 staff short of being able to increase this to 10, which taking the patient bringing out of seclusion on 2 to 1 would require. Staff later terminated the patient’s seclusion 1 hour and 20 minutes after the decision that seclusion could be terminated was made.

The average percentage sickness across all wards as of June 2025 was 6%, slightly higher that the NHS average of 5.6%. The highest percentage of staff turnover was on Fern (12.2%) followed by Maple (11%), Sycamore (10%) and Brook (10%) wards. The average turnover levels across all forensic wards were 1%. The highest turnover rate (4%) was for Seacole ward (CAMHS) and Willow ward (medium secure).

During our inspection, we visited Fairbairn ward, a medium secure national deaf service for adult men with complex mental health needs. The provider’s web site stated at the time of our inspection that “Over a third of our nursing team are deaf and all staff and patients are trained in British Sign Language (BSL) ensuring greater engagement within the unit and participation in therapy”. However, despite the service's stated commitments to “culturally appropriate and linguistically inclusive care for deaf patients”, the current ward operations fell significantly short. There were systemic communication failures, a lack of deaf cultural competence, minimal structured activities, and poor managerial oversight. We found that there was both a lack of interpreters, and a lack of access to interpreters. These deficiencies were having a direct, negative impact on patient care, staff morale and therapeutic outcomes.

Our findings have revealed a significant breakdown in the principles, vision and practice of a service which had been designed to empower deaf men with complex mental health needs. The absence of deaf staff, failure to provide culturally and linguistically appropriate care and lack of effective leadership jeopardise the safety, dignity and therapeutic recovery of patients. Immediate action is required to address these failures and restore the integrity of what should be a national model of excellence.

Over 80% of staff had received and were up to date with appropriate mandatory training. The training was appropriate for the patient group using the service. For example, 75% of staff had completed autism awareness training; however, 25% of staff within the Learning Disability and Autism (LD/A) service had not. In addition, there was limited availability of staff trained in British Sign Language (BSL). This had been identified as a risk on the service’s risk register. Despite the high level of training compliance and the view of staff members on the training offered, we often found staff were not applying this training in practice, such as safeguarding, which led to significant risks to patients.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.