- 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 - Services for people with acquired brain injury
Our view of the service
This inspection of services for people with acquired brain injury at St Andrew’s Healthcare Northampton took place in July and August 2025. This inspection was undertaken due to ongoing concerns CQC had received about the service, including a poor standard of care and numerous safeguarding concerns of allegations of abuse from staff to patients.
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.
In the neuropsychiatry division of the location, there were 5 wards for people with acquired brain injury at the time of the inspection. These consisted of; Tavener ward, Church ward, Allitsen ward, Elgar ward and Tallis ward. The service made the decision to close Church ward shortly following this inspection. The division also has Walton ward, a specialist ward for male people living with Huntington’s disease. During this inspection, we focused upon 3 of these wards:
- Tallis ward – an admission, assessment and rehabilitation ward for males (11 beds).
- Elgar ward – an admission, assessment and rehabilitation ward for females (12 beds).
- Walton ward – an admission, assessment and rehabilitation ward for males living with Huntington’s disease (14 beds).
The service was registered to provide treatment of disease, disorder or injury and assessment or medical treatment for persons detained under the Mental Health Act 1983.
There was no registered manager in post at the time of this inspection.
At this inspection, we identified breaches of regulations: 10 dignity and respect, 12 safe care and treatment, 13 safeguarding service users from abuse and improper treatment and 17 good governance.
We rated the service as Requires Improvement. We found breaches relating to a lack of risk mitigation, patients being kept safe from potential abuse, patients not being treated with dignity and respect, and some shortfalls with monitoring the service to make improvements in patient care. We found staff did not consistently protect people from abuse and improper treatment, staff did not always successfully mitigate individual patient risks where identified and governance systems and audits had not always been effective in identifying or addressing areas for improvement.
However, we found where possible, patients were supported to have choice and control and could give feedback on their care through regular community meetings. We noted the service had undertaken some work in relation to blanket restrictions following our previous inspection.
Staff we spoke with were happy working at the hospital and felt supported by their line managers. Ward managers had systems in place enabling them to monitor staff performance and care delivery, although poor practice had not always been identified. We met some staff who were very passionate about making a difference to patients they cared for. Patients were encouraged and supported to maintain contact with people who mattered to them.
Mental Health 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, which could be accessed when needed.
Staff received and kept up to date with training on the Mental Health Act, which was mandatory for staff. Compliance was over 90% at time of inspection.
Staff had access to support and advice on implementing the Mental Health Act and its Code of Practice. Staff could access support from the providers’ Mental Health Act administration department.
The service had relevant and up-to-date policies and procedures that reflected relevant legislation and the Mental Health Act Code of Practice.
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 had access to an Independent Mental Health Advocate (IMHA). Posters were displayed on noticeboards on the wards with contact details to reach this service. Provision of the advocacy service had changed, with access through the Local Authority. This meant patients had access, but not as easily as previously where drop-in sessions had been facilitated by advocates visiting the wards.
Mental Capacity Act Compliance
Staff received training about the Mental Capacity Act and the five principles. Training on the Mental Capacity Act and Deprivation of Liberty Safeguards were incorporated into mandatory training on Mental Health Law. Compliance was over 90% at the time of inspection.
Individuals’ capacity to make decisions was monitored and recorded at multidisciplinary team meetings.
People's experience of this service
Most patients we spoke with during this inspection told us they felt safe on the wards. Most patients we spoke with (7 out of 10) spoke positively about the staff. Patients used phrases such as “the staff are nice”, or “they are kind and respectful”.
One patient told us staff did not interact with patients when they were sitting with them on enhanced observations. They further claimed they had heard staff speak to one another in a language other than English. The patient went on to say that “staff do not listen” and “if you complain you are seen as being aggressive”.
One patient said of the staff “I do not like the staff… except for one… the rest are horrible”. However, we could not elicit further information to add context to this statement.
One further patient said some staff are “kind and respectful and some are not”. They went on to say how some staff had helped them during a difficult time, while other staff had not.
We spoke with 3 carers of people who were using the service and obtained feedback from 3 relatives of people who were using the service. Feedback was mixed. Three carers generally spoke positively about the care and treatment of their relatives. They confirmed that they were able to maintain contact with their relative, via telephone or through visiting.
One carer said that the staff did try to positively engage with their relative and said some members of staff are “good with them”. This relative said that staff “did their best” and they had not needed to raise any concerns with the team.
Another carer stated the staff “had done a marvellous job…. their relative had made real progress since they have been there”. The only minor concern raised, was the lack of communication with regards to what was happening in relation to their care and treatment. The carer said they used to receive regular updates but said they got nothing now.
Three concerns had been shared with us relating to care and treatment on Tallis ward. The relatives had also shared their concerns with the hospital, and in some cases, the Local Authority. One concern was relating to numerous, unexplained injuries on a patient. This was being investigated at the time of our inspection.
Further concerns raised were around a patient engaging in activities their relative did not feel was appropriate and considered this to be undignified. The hospital addressed this, had responded to the relative and was monitoring the situation.
A third concern shared was around a delay in appropriate, physical healthcare. The hospital had investigated this and had communicated the findings to the relative.
While the people using the service we spoke with expressed they were happy with their care, our inspection found elements of the care did not meet the expected standards. Work had continued with recruitment since our last inspection. The service continued to use regular bank and agency staff to cover gaps.