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 previous inspection we rated this key question requires improvement. At this inspection, the rating has remained requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

At the previous inspection, the service was in breach of a legal regulation around safeguarding, specifically restrictions placed upon patients. We will need to continue to monitor to establish when relevant actions have been taken and the breach has been resolved.

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

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 consistent, proactive and positive culture of safety based on openness and honesty. They did not always listen to concerns about safety. Lessons were not learnt to continually identify and embed good practice.

The service had processes in place to enable staff to report incidents and to learn from investigations. However, we did not find lessons learnt which had been shared with staff had been successfully embedded to demonstrate continual learning and best practice.

On the 3 wards we visited, staff were aware of the incident reporting process. Within care records we reviewed, we saw a wide range of incidents had been reported by staff, in line with the provider’s policy.

All staff we spoke with told us they received feedback regarding lessons learnt following incidents. Staff explained this was at individual ward level, directorate level and hospital wide. Staff we spoke with told us lessons learnt were relayed to staff mainly via email and through hospital bulletins.

We reviewed some meeting minutes across the wards which did reflect some discussions around recent incidents and some lessons learnt that had been identified. We also saw some email correspondence to managers, requesting that specific lessons learnt were cascaded down to the teams at ward level.

Most staff told us they had to read and sign to confirm they had read lessons learnt information that had been circulated yet were unable to share any recent examples with us. We spoke with 16 staff members. We asked staff for an example of some lessons learnt following an incident, either specifically related to the services for people with acquired brain injury, or the wider hospital. Only 4 out of the 16 staff members (25%) were able to provide an example of some recent learning. While we were assured there was a process in place to cascade learning, we were not assured it was effective.

In April 2025, we saw a bulletin had been cascaded to staff following an incident which had resulted in a foot injury to a patient. Part of the lessons learnt included staff must ensure that patients wear appropriate footwear. In June 2025, we saw a further lesson learnt bulletin, cascaded following a foot injury to another patient on another ward. Part of the lessons learnt included that staff must ensure patients wore appropriate footwear. This did not demonstrate staff had learnt from the incident in April 2025. During both incidents, the patients did not have any footwear on.

In May 2025, we saw a lessons learnt bulletin, following the identification of a de-facto seclusion. This meant that staff prevented a patient from leaving a certain area of the ward. In this instance, it had been a bedroom. Staff were informed that patients must not be prevented from leaving a room or any enclosed area by staff unless they were following the relevant seclusion policy. However, CQC identified there had been further incidents of this nature between May and August 2025 across the hospital. This did not offer assurances that staff on the wards had taken previous lessons learnt and ensured this issue did not occur again.

We reviewed an ‘after-action review’ (AAR) following an incident in July 2025. In the provider’s policy, an after-action review is described as a “group learning process”. The review had been undertaken by a ward manager and a patient safety practitioner. This review was not comprehensive. There was a lack of analysis, system learning and good practice identified. There was nothing within the review about how lessons learnt would be shared more widely, or who would be responsible for this.

We saw 3 further reviews of incidents, entitled a “fact find”, completed in May and June 2025. Two out of three of these reports were not as comprehensive as they could have been. For example, there was a lack of detail regarding the potential explanation of an unexplained injury. Findings of the review in one were a list of actions. There was a lack of detailed analysis to share with staff and the wider team.

The evidence showed some shortfalls. The service 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.

The service did not adequately monitor patients’ safety and staff had not always protected patients from harm. During this inspection we identified some unexplained injuries to patients, and incidents considered to be a near miss, where patients could have potentially come to harm, due to observations not carried out in line with the provider’s policies and processes.

The service worked with partners to ensure transfers in and out of the hospital were undertaken in a safe, planned way. At the time of inspection, CQC had placed a restriction on new admissions across the hospital and therefore the 3 wards we visited had not admitted any new patients recently.

Staff on all 3 wards we visited confirmed that new admissions to the service were planned. However, these admissions would no longer go ahead due to the restriction on admissions imposed by CQC. Relevant multi-disciplinary team members (MDT) undertook an initial assessment to see if the proposed ward could meet the patient’s needs. If in agreement for admission, relevant information regarding the patient, to include care plans, positive behavioural support plans and risk documents would be shared with the ward team prior to the patient being admitted. Staff were able to access this information, via email, and in paper form which was stored in the nursing office. Managers encouraged staff to familiarise themselves with the patients’ needs prior to them being transferred.

Staff communicated with referring partners to discuss individual patient requirements to ensure as smooth a transition as possible, enabling sufficient resources and/or equipment required, where relevant.

We saw there had been some transfers internally within the division, which had been considered at senior level. Transfers within the services for people with acquired brain injury were generally from the initial assessment wards, onto wards with a focus on continual rehabilitation, and had been agreed by relevant commissioners.

Staff undertook monthly audits of enhanced support care across the wards. The audit covered different aspects about individual patients enhanced support, to include the need for this, how observations could be reduced, documentation, guidance for staff to maintain as much privacy and dignity as possible, as well as overall engagement and activity. While we saw staff had completed these audits, we did not see who would be responsible for actioning areas that needed improvement. On one ward, we noted one patient’s enhanced support had been audited in January 2025 and again in April 2025. We saw there were still shortfalls in many areas in April’s audit, which had been identified in January. These shortfalls included the reason enhanced observations had been commenced, how staff could work with the patient to reduce observations, a lack of guidance for staff around privacy and dignity, as well as a lack of detail in recordings of engagement and any offered activity. This showed the findings of the audits had not been actioned.

The evidence showed significant shortfalls. The service did not consistently 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 safely, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. They did not always share concerns quickly and appropriately.

Staff had received training in the safeguarding of adults and children which was updated regularly. Staff we spoke with knew what safeguarding concerns they needed to report and escalate.

Across the 5 wards (at the time of inspection) for patients with acquired brain injury, and Walton ward, a total of 40 safeguarding concerns had been reported to the Local Authority between 1 May and 17 August 2025. The 3 concerns reported most frequently were allegations of abuse by staff to patients (52%), physical aggression / violence between patients (22.5%), and unexplained injury / physical health (17.5%). There were several staff who had been suspended from working, pending investigations, across the division, following allegations of psychological, sexual or physical abuse by staff to patients.

Shortly following this inspection, one of the wards not visited (Church ward) was closed by the provider. CQC were aware that there had been allegations of abuse on Church ward by staff to patients, of which an ongoing internal investigation continues. The provider had informed CQC of this incident via a Statutory Notification, and had continued to update us of progress.

On one ward, we noted there had been 2 recent incidents of physical altercations between 2 patients. Upon further exploration of records, it transpired this was something that had occurred previously. Incidents of this nature between the 2 patients had occurred earlier in the year, in February and April 2025. This did not demonstrate that effective measures had been put in place to minimise further incidents between these 2 patients. The Local Authority were conducting a safeguarding investigation into this at the time of inspection (Section 42 enquiry).

Each ward had a restrictive practice log which gave a rationale for restrictions imposed upon patients. We saw there had been some improvements around the number of blanket restrictions across the wards. Some restrictions had been individually risk assessed, such as the use of metal cutlery and vaping times. Restrictions across all wards need to be regularly reviewed and justified.

One patient on Walton ward had recently been involved in a prolonged restraint. Staff explained that taking the patient to seclusion had been considered. However, Walton ward had no seclusion room. This meant staff would have had to transfer the patient through the ward, and on to another ward to a designated seclusion room, which they deemed as unsafe at that time. We were concerned that the lack of facility on the ward had resulted in a lengthily restraint.

We saw from a patient record that an unexplained injury was recorded, noted towards the end of being assisted with personal care. The injury had not been observed at the commencement of the personal care. The staff had assumed that this was a self-inflicted injury. We were concerned that this was unexplained, as the patient’s care plan stipulated the patient always required staff presence and support with personal care. Therefore, we would have anticipated a clear explanation of how this had occurred. Staff did report this as an incident, in line with the provider’s policy.

There was limited evidence to suggest restraint was always used as a last resort on the wards we visited. We reviewed one set of patient records on each ward in detail, as staff had told us restraint was frequently used with these patients.

In one set of records, we saw one patient had daily incidents of restraint, when staff were assisting them with personal care. Staff did not detail if verbal de-escalation was attempted first in most incident reports reviewed. We saw numerous examples when staff completed incident forms but had not entered corresponding information in the daily progress notes.

In another clinical record, we saw frequent entries by staff which referred to the patient becoming agitated during personal care and required 4 members of staff. We failed to locate corresponding incident forms for all recent entries.

In another clinical record, it stated a patient required a team of staff to assist with personal care needs. Four staff, 3 to support and 1 to be available if needed. This was another example whereby staff appeared to routinely use several staff members to assist the patient but failed to record on incident forms and / or make detailed entries in clinical daily notes.

Staff we spoke with told us these patients had care plans to be restrained when they presented as physically resistive. We were concerned that restraint had become seen to the staff as “usual” and “expected” when assisting with personal care, as opposed to being focused upon working with the patient to reduce distress and aim towards no, or reduced restraint during activities of daily living. All patients had a positive behavioral support plan, but it was not evident that these were being followed by staff.

The evidence showed some shortfalls. The service did not always work well with people to understand and manage risks. They did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff told us they made every effort to work with patients, where possible to safely manage known areas of risk. Staff reviewed patient risk documentation regularly. In some care plans we reviewed, staff had recorded the patient had been unable to contribute to the care plans, due to complex mental health needs. There was a lack of patient voice in some documentation seen. We saw a missed opportunity for staff to involve relatives in some instances. If staff had discussed some of the care plans with carers / relatives, it had not always been recorded.

Staff supported a patient to take informed risks. In one case, a patient wanted to enjoy certain foods, although they knew certain textures had been advised against. We saw there had been several discussions about this, with relevant multidisciplinary team (MDT) members, to ensure the patient was aware of risks and potential consequences of eating foods advised against. A capacity assessment had been completed, and an appropriate plan of care implemented. This offered the patient a greater choice of foods, which they were pleased with, as well as ensured staff had clear guidance in how they could support the patient’s choices in a safe as way as was possible.

A patient on one ward had a severe food allergy. To ensure all staff and patients were aware of this, the staff team discussed this during a community meeting. It was agreed that, due to the potential seriousness of the patient coming into contact with certain foods, these should not be bought onto the ward. Staff and patients had agreed to this. Relevant visual posters were displayed on the ward, including on the main door to the ward to act as a reminder. However, during our inspection, we identified that a patient had bought in one of the restricted food items and had placed it in the ward fridge. As soon as staff observed this, it was removed. However, we were concerned that a patient managed to purchase and store this food on the ward, due to the potential adverse reaction it could have caused. This did not give assurances around routine checks and procedures staff undertook when patients returned from leave.

Staff had identified that a patient had proceeded to colour their hair on a ward, without informing staff. Staff discovered this when they routinely checked the patient and noted the hair dye had been freshly applied. Previously, staff had spoken with the patient and explained that while they were happy for their hair to be coloured, to ensure safety, staff would supervise and ensure relevant skin tests were completed prior to using the purchased product. Staff did monitor this patient when they realised hair dye had been applied. The patient did not come to harm, and an incident form was completed. These 2 incidents did not assure us that staff meticulously monitored what patients purchased and brought onto the ward.

One patient on another ward was at risk of falling. We reviewed documentation relating to 5 falls experienced in June and July 2025. All falls had been recorded in the daily clinical notes as we would expect. However, staff did not complete all documentation relating to falls in 4 of the 5 incidents reviewed. There had been an absence of some body maps and post falls assessments. This was highlighted to the ward manager, who was aware and had spoken with staff to reiterate the importance of comprehensive documentation. This was important as this patient had been found to have unexplained injuries.

Across the neuropsychiatry division, a specific, adapted tool was used to record different behaviours. These could be verbal, physical or sexual, which were viewed as positive, or inappropriate. In guidance seen, specific to this tool, it was not explicit when verbal or physical behaviours should be additionally reported via an incident form. Most staff we spoke with confirmed physical assaults would be reported via an incident form, whereas verbally inappropriate behaviours, such as persistent shouting out, or insulting others, would not be recorded on an incident form, but captured within the specific tool.

The psychology team regularly reviewed data from the tool with the wider multi-disciplinary team to help identify patterns of behaviour and support intervention plans. We were concerned that staff may have been inconsistently recording behaviours in different places, making interventions and progress more difficult to track. Some staff acknowledged data could be captured more accurately. This point had been discussed with staff at a ward meeting on Tallis ward in June 2025.

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 some shortfalls. The service did not always make sure there were enough qualified, skilled and experienced staff. They did not always work together well to provide safe care that met people’s individual needs.

Most staff we spoke with told us staffing had been an ongoing concern for some time. However, most told us they now usually had adequate staffing levels. Staff across each ward reported there had been a recent uplift to staffing. Staff on Walton and Tallis ward informed us they had recently been given an additional registered nurse on the day shifts, taking registered staff nurses from 2 to 3. Additionally, a registered nurse was working the twilight shift on Tallis ward, which covered up until midnight. This was reflective in ward rotas seen. Senior staff told us recruitment of staff across the wards had been an area of focus over the past few months. Staff tried to work with one another to meet patient needs. For example, MDT staff members might cover staff breaks to ensure there was an adequate presence on the wards. Therapy staff could assist with patient leave, but this was dependent upon their individual workload and priorities.

There were qualified (registered nurse) and unqualified (health care assistant) vacancies across all 3 wards visited. The highest reported number of vacancies was on Elgar ward. The establishment was 9 nurses, they had 3 vacancies (33%). The establishment for health care assistants was 60, there were 18.7 vacancies (31%).

Walton had 1 qualified vacancy out of an establishment of 7 (14%). The establishment for health care assistants was 31, there were 4 vacancies (12%). Tallis had 2 qualified vacancies out of an establishment of 7 (28%). The establishment for health care assistants was 49, there were 3 vacancies (6%).

The service continued to use bank and agency staff regularly. We observed that regular staff across the division also worked overtime to help cover gaps. We examined bank and agency use between May and the end of July 2025 across the 3 wards visited.

We saw there had been a reduction in the use of bank and agency staff on Elgar ward, which was reflective of new starters. In May 2025, bank staff had been used daily. This reduced in June 2025 to 53 out of 60 shifts, and further in July 2025, with bank staff being used in 16 of 62 shifts. Agency staff had decreased significantly since the onboarding of new starters. In May 2025, agency staff were used in 20 out of 28 shifts: in June 2025, 24 out of 60, and in July 10 out of 62. Over the three-month period, the combined bank and agency staff usage varied daily between 0% and 53%.

On Tallis ward, bank staff continued to be used regularly. In May 2025, bank staff were used to cover 55 out of 62 shifts. In June 2025, 53 out of 60 shifts. In July 2025, 52 out of 62 shifts. Agency staff were still used, but this was decreasing. In May 2025, the ward used agency in 44 out of 62 shifts, in June 2025, 34 out of 60, and in July 2025 19 out of 62. Over the three-month period, the combined bank and agency staff usage varied daily between 0% and 60%.

On Walton ward, bank staff continued to be used regularly. In May 2025, bank staff were used to cover 58 out of 62 shifts. In June 2025, 58 out of 60 shifts. In July 2025, 59 out of 62 shifts. Agency staff were still used, but this was decreasing. In May 2025, the ward used agency in 40 out of 62 shifts, in June 2025, 28 out of 60, and in July 2025 14 out of 62. Over the three-month period, the combined bank and agency staff usage varied daily between 0% and 53%. The decline in the use of agency staff helped to provide consistency on the wards for patients so this was positive. Use of bank staff remained high and regular staff continued to work overtime across the service to fill gaps.

Sickness across the wards visited, between May and August 2025, had varied between 0.8% and 5.1%, which was below the current national average. Most sickness reported was due to short term illness, with themes of gastro-intestinal problems and migraine. Of the 3 wards we visited, Tallis had the highest sickness rates, followed by Walton and Elgar.

Staff we spoke with told us they received adequate training and support to undertake their roles. All staff attended a hospital induction and got the opportunity to spend some time on their allocated wards before they were officially counted in the ward staffing numbers. All staff had to complete mandatory training, and there was a selection of non-mandatory training available. Managers monitored training compliance and took actions to ensure staff updated skills and knowledge as and when required. Mandatory training across the division has consistently been over 90% compliance. Some staff on the wards had received some specific training about acquired brain injury. We were informed that further specialist training around Huntington’s disease was also being made available for staff who had not previously completed it.

Despite the high level of training compliance and the view of staff 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.