- 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 - Wards for older people with mental health problems
Our view of the service
This inspection of wards for older people with mental health problems 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 3 wards for older people with mental health problems. These consisted of Cherry ward, Aspen ward and Redwood ward. The service made the decision to close Elm ward before our inspection took place and Aspen ward closed immediately before our visit. During this inspection, we visited 1 ward (Redwood ward) and reviewed data for 3 wards:
- Redwood ward – a specialist older adult service for males with c complex dementia and / or progressive neurological conditions, who present with cognitive deficits (12 beds).
- Cherry ward - a specialist older adult service for females with complex dementia and / or progressive neurological conditions, including Huntington's disease, who present with cognitive deficits (12 beds).
- Aspen ward - an admissions service for males with complex dementia and / or progressive neurological conditions, who present with cognitive deficits (8 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 have rated the service Inadequate. The provider was in continued breach of 5 Regulations; person-centred care (Regulation 9), safe care and treatment (Regulation 12), safeguarding (Regulation 13), staffing (Regulation 18) and good governance (Regulation 17).
This was an unannounced inspection, which means the service was not told an inspection was going to be taking place beforehand. The inspection was carried out in response to a serious incident of concern. During this inspection we looked at quality statements within the Safe, Caring and Well-Led key questions. The scores for these areas have been combined with scores based on the rating from the previous inspection, which was rated as Inadequate.
Staff continued to not consistently deliver safe care and treatment to keep patients safe. Not all patients were supported to remain safe. Staffing numbers remained insufficient to meet patients’ needs or keep them safe. This had a significant negative impact on outcomes for patients and created barriers to staff members to provide good quality person centred care.
Patients continued to not receive person centred care because staff were not effectively applying the provider’s chosen model of care ‘enhanced dementia care’. Staff did not always have time to read care plans, so they fully understood patients’ needs and preferences.
The learning culture across the division remained ineffective. Patients were not always protected from improper treatment. There was no evidence of consideration of the least restrictive way to manage the personal care for 1 patient. This was causing the patient distress for most personal care interventions and a lack of clear therapeutic plan of care. Not enough action was taken to manage patient’s distress.
There was a delay in identifying injuries and records did not always provide enough detail or accurate detail. Body map records of injuries found on patient’s bodies were not always followed up or there was a delay. Not enough detail was provided about the nature of the injuries.
At our previous inspection we identified the blanket use of plastic cutlery, this was still the case at this inspection, however we were told plans were underway to carry out individual risk assessments.
Leaders continued to fail to have a clear oversight of risk and quality monitoring on the wards. Governance processes remained ineffective including seeking feedback from patients or establishing methods to gain an understanding of patient’s experience. However, communication with patients’ relatives or significant others was good.
This assessment service group was most recently inspected in March and April 2025 and rated as Inadequate.
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 received training on the Mental Health Act and the Mental Health Act Code of Practice and could describe the Code of Practice guiding principles. Online training on the Mental Health Act was mandatory for all staff.
Staff had access to support and advice on implementing the Mental Health Act and its Code of Practice.
The service had the relevant policies and procedures that reflected all relevant legislation and the Mental Health Act Code of Practice. The service had developed procedures for the implementation of the specific sections of the Act. These procedures each included a checklist for staff to complete to support legal compliance.
Patients had easy access to easy read information about their rights under the Mental Health Act. However, many patients had cognitive impairments which meant they had difficulties processing this information, so patients’ relatives were involved and consulted.
After our previous inspection the providers arrangements for accessing advocacy services changed. We were concerned this would result in a reduced access to these services. Clinical governance meetings recorded there were ongoing issues with access to advocacy and social work support because of known capacity issues in the wider Northamptonshire area.
Staff requested an opinion from a Second Opinion Appointed Doctor (SOAD) when they needed to. SOAD’s were requested by the patient’s responsible clinician.
Staff stored copies of patients’ detention papers and associated records correctly and could access them when needed.
Managers and staff made sure the service applied the Mental Health Act 1983 correctly by completing audits and discussing the findings. The implementation of the policy was overseen by the Mental Health Act Steering Group comprising of the Mental Health Act lead, a clinical director, a solicitor, responsible clinicians, nurses and social workers.
Mental Capacity Act
Staff received training about the Mental Capacity Act and understood the five principles. Training on the Mental Capacity Act and Deprivation of Liberty Safeguards were incorporated into mandatory training on Mental Health Law.
Individuals’ capacity to make decisions was monitored and recorded at multidisciplinary team meetings. However, restrictions regarding access to ordinary cutlery had been imposed without appropriate consent or rationale. We were concerned this decision had not considered individual patients’ best interests as is required by the Mental Capacity Act 2005. The restriction was imposed as a blanket restriction to keep patients safe from others with an identified risk. Staff did not adopt the least restrictive principle such as facilitating access to cutlery in safe way or developing a person-centred care plan in relation to eating and drinking needs.
People's experience of this service
We spoke with 1 patient on Redwood ward. We used CQC’s Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of patients who could not talk with us. We saw a mixed picture with some positive interactions between patients and staff and some patients receiving little attention or interaction. We saw one patient was distressed but there were no staff available to offer support or reassurance.
Patients had limited access to activities that were meaningful to them or access to leave outside of the ward. Some patients had a poor quality of life and had been on the wards for several months.