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 Inadequate. At this inspection the rating has remained Inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in continued breach of legal Regulation 12 in relation to safe care and treatment, Regulation 13 safeguarding service users from abuse and improper treatment and Regulation 18 staffing.

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. Lessons were not learned to continually identify and embed good practice.

Some lessons learned were shared with staff across the division and hospital wide. Examples were provided of lessons learned shared, such as an incident where there was delay in the escalation and management of care in an emergency. Staff were reminded of the correct procedure to follow. Another example included staff preventing a patient leaving a room by blocking the door and creating a de-facto seclusion. Staff were informed that patients must not be prevented from leaving a room or enclosed area by staff unless they were following the seclusion policy. However, CQC were made aware of further incidents of this nature between May and August 2025 across the hospital. Therefore, we were not assured that learning from incidents and safety concerns was embedded into staff practice.

We reviewed team meeting minutes for May, June and July 2025 for Redwood and Cherry wards. Although patient safety and learning from incidents was a standard agenda item within ward team meetings, we did not see any records of the lessons learned bulletin items being discussed.

Some concerns and breaches of regulation we identified at our previous inspection were ongoing, although with some action taken. However, at this inspection we did not see any resolution or effective risk management in place for the concerns raised. For example, the provider’s risk register recorded a high risk for staff compliance with dysphagia (difficulty with swallowing and choking risk) training. Although compliance with this training for permanent staff was high, agency staff had not received this training. Therefore, this remained a concern at this inspection. Due to the high dysphagia risks identified on Redwood ward, this was a concern. This showed there was a lack of, or significant delay, in learning lessons from identified safety concerns and ongoing risk was not effectively managed despite being raised at previous inspections.

At our previous inspection we identified staff were not following the provider’s chosen model for dementia care; ‘The Enriched Model of Dementia Care’. This resulted in a reduced quality of life for patients living with dementia, many of whom had been on these wards for more than a year and longer. At this inspection we found no improvement or resolution to this concern and this risk is recorded as a ‘high risk’ on the provider’s risk register with additional specialist training not planned to take place until September 2025. This was further evidence of significant delays in learning lessons being embedded in response to risks.

Three serious incidents which resulted in harm to patients on the older people’s wards were under investigation at the time of this inspection.

Staff we spoke with demonstrated an understanding of the process for reporting incidents. They told us incidents were discussed during staff handovers. Most staff said they were given feedback about action taken. Some staff were unsure if non-permanent staff members from an agency would know what to report.

There was closed circuit television (CCTV) in operation in communal areas. Since our previous inspection, leaders had begun to routinely review the CCTV footage following incidents. We reviewed CCTV of an incident on Redwood ward where a patient fell. The review showed the incident report contained inaccurate information in relation to what occurred. Review of the incident also evidenced that the fall could have been anticipated and prevented, and there was limited compassionate care provided to the patient after the fall.

Staff had access to reflective practice sessions with a psychologist, however, clinical governance meetings in May 2025 recorded “Reflective practice sessions are happening, though attendance is limited due to staffing shortages and difficulty securing multidisciplinary team cover”.

Records showed staff had communicated with patients’ families when things went wrong. They provided families with information and updates.

The evidence showed significant 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, including when people moved between different services.

Staff told us they had a limited and ineffective handover when Elm ward was closed, and 4 patients moved across to Redwood ward. Another staff member told us they did not have time to get to know the new patients or read their care and treatment plans.

Action plans were in place for each ward to address action required in response to incidents or identified shortfalls. For Redwood ward, the action plan included action required following a patient fall where it was identified staff were not adhering to care plans. Actions identified that consideration should be given to ensuring adequate staffing levels during high-risk periods to always maintain safe cover on the ward. We were concerned these actions had not been embedded into day to day practice to ensure safe systems of care.

Ward team meetings highlighted several ongoing safety issues, which had not been addressed, or there was a delay in taking action to resolve these patient safety concerns. For example, since May 2025, staff on Redwood ward had been raising concerns about insufficient staffing numbers impacting on their ability to provide quality care and treatment. This had resulted in a lack of opportunities for patients to take part in activities or to leave the ward for any activities. These issues were ongoing at the time of this inspection, and we were not assured safe systems of care had been established or maintained.

At our previous inspection in March and April 2025 we were concerned about the high incidence of late recording of enhanced observations. The provider told us this was a recording issue and that while observations were recorded late, they did take place at the prescribed time. However, we remain concerned the process for reviewing and auditing staff adherence to carrying out enhanced observations was not effective if staff continued to record the observation after the prescribed time. The provider sent us audit results which recorded these observations had been consistently completed in line with prescribed enhanced support levels for this time period. However, failure to follow the enhanced observation process was on the provider’s risk register as ‘high risk.’

At our previous inspection in March and April 2025 we were concerned that the provider’s ligature risk assessment was not effective. At this inspection, we found the provider had updated their risk assessment. However, we remained concerned because “good observation” had been recorded on the ligature risk assessment as a control measure to manage the risk. However, during our visits in July 2025 we saw staff were very busy and were not able to observe patients while in the communal areas at all times.

We reviewed details of a complaint relating to a relative not being informed or consulted about their family member moving to a different ward. The complaint submitted by the patient’s relative was investigated and substantiated.

The evidence showed significant shortfalls. The service did not work well with people 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.

We found evidence of a hospital wide closed culture (a harmful culture where staff lose sight of people as individuals, leading to increased risk of abuse, human rights breaches and harm) resulting in improper and abusive treatment of patients. We took urgent enforcement action to impose a condition on the provider’s registration to restrict new admissions across the entire location. CQC agreed with the provider for them to undertake regular reviews of incidents involving restraint which included watching relevant CCTV footage, as well as maintaining efforts with staff training and awareness around closed cultures, with weekly reporting to CQC on the outcomes. The provider has also sought external support with a hospital wide culture review.

The provider sent us data regarding all safeguarding incidents from May to August 2025 across the wards for older people with mental health problems. For the older people’s ward Elm, Aspen, Cherry and Redwood (the provider notified CQC that Elm and Aspen wards have closed) there were a total of 15 safeguarding concerns reported to the Local Authority. The decision to report to the Local Authority is decided by the multidisciplinary team.

On Aspen ward 2 incidents involved allegations against staff, improper treatment or abuse and 2 involved physical health needs. The physical health concerns related to 1 case of bruising with unknown cause and another regarding admission to hospital with dehydration.

On Cherry ward there were 3 safeguarding referrals sent to the Local Authority. These included an unwitnessed fall, unexplained bruising and an allegation against a staff member.

On Redwood ward there were 6 safeguarding referrals sent to the Local Authority. Four injuries with unknown cause and 2 altercations between patients.

On Elm ward there were 2 safeguarding referrals sent to the Local Authority. One fall from lifting equipment and one delay in escalation in the response to a medical emergency.

Staff received safeguarding training and compliance with this training was 100%. Staff we spoke with were aware of the provider’s safeguarding vulnerable adults’ policy and told us they understood their responsibilities to identify and report abuse. However, while the provider followed the correct procedure once the incidents had been identified as potential abuse, we were concerned patients were not always protected from abuse and the provider had insufficient processes in place to identify abuse. This was due to a delay in staff identifying and reporting potential abuse in 7 of the 15 incidents. Delays were due to staff not identifying or reporting the abuse (finding older yellow bruising), abuse being identified through review of CCTV footage or staff coming forward following staff safety interviews and not at the time the alleged abuse was witnessed. In addition to this, we identified some concerns during our review of CCTV that the provider had not identified themselves.

At our previous inspection in March and April 2025 we were concerned about the use of restrictive practices because of blanket restrictions used across the older people’s wards. At this inspection we found the number of blanket restrictions had reduced. For example, patients were no longer restricted to accessing snacks and some work had taken place to review the restriction of access to cutlery (patients only had access to plastic cutlery). However, at the time of our visits, patients on Redwood ward continued to be restricted for the use of cutlery. We were told each patient would have an individual risk assessment regarding access to cutlery. However, this process had been delayed following a trial on 1 ward where a patient had snapped a spoon in half. In response, the provider was sourcing a safer and more appropriate cutlery product. However, there had been a considerable delay in taking action about the use of this restrictive practice. This meant patients potentially continued to be unnecessarily restricted without appropriate consideration of individual risks.

Staff had received training about restrictive practice and restraint known as ‘safety intervention training’. Compliance with this training was at 100%. Staff we spoke with understood their responsibilities to comply with these policies and acts. However, 1 patient was restrained daily by 3 staff to support delivery of personal care. Some staff were unsure if this was restraint which required reporting on the provider’s incident reporting systems. There was limited evidence to show if alternative less restrictive methods for providing personal care had been considered or trialed. The provider had a ‘least restrictive practice policy’ to promote the reduction of restrictive practices. This policy stated restrictions should only be applied for the shortest possible time, but the 3 to 1 staff restraint had been ongoing for several months with no plan in place to reduce.

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, supportive and enabled people to do the things that mattered to them.

Ward representatives and multidisciplinary team members attended daily risk management (divisional huddle) meetings (Monday to Friday). Incidents, areas of concern, staffing and complaints occurring in the previous 24 hours were discussed so that lessons could be learned, and any known shortfalls could be escalated and planned for. However, we were concerned that not all risks or areas of concern had been brought to these meetings, or that the meetings were effectively impacting on safety and risk management for day-to-day practice on the wards. Clinical governance meeting minutes for Cherry ward in May 2025 recorded a concern about information from divisional huddles not always being communicated within ward handovers. Action was taken to improve this through the use of signed handover records to ensure clarity and audit trail. Some staff we spoke with were not aware of all known current risks we saw recorded in patient’s records.

On Redwood ward, we reviewed 6 patient care records and risk assessments. Three patients had several body map records recording visual damage to their skin. One patient had 19 body map records within a 10-month period. Many body map records did not clearly record or describe what the damage was or what staff had seen. There was not always corresponding information recorded within progress notes or any recorded action of investigation or escalation. This meant there was a lack of oversight regarding the safety of patients or consideration of if the harm experienced was avoidable.

Another patient on Redwood ward had a high falls risk and had 18 body map records in a 12-month period and had sustained bruising. During our visit we saw this patient was distressed, attempting to open locked doors and get the inspector’s attention through the office window. The patient was walking in an unsteady way and was at risk of falling. This patient was on 15-minute observations, but records evidenced staff frequently had to provide one to one support to keep them and others safe. Staff were very busy supporting other patients; however, this additional support was not factored into the staffing numbers provided.

We reviewed CCTV footage of an incident on Redwood ward. We found the incident report contained inaccurate information in relation to what occurred. The registered nurse recorded that the healthcare assistant told them they did not observe the fall, as at the time of the incident they were attending to another patient. CCTV evidenced the staff member did observe the fall. We saw the patient had a very unsteady gait and a fall could be anticipated. The member of staff observing them took no action. The patient fell and the response to the patient on the floor was not timely. Staff were observed to be standing over the patient and did not get down to communicate with the patient at their level.

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.

At the time of our inspection on Redwood ward there were 10 patients and 9 staff deployed. Two patients required a staff member with them at all times to ensure they were safe. One patient required 15-minute observations but frequently required additional support because of their distress and falls risk. Another patient required 3 staff to support them with personal care. Two patients required 30 minute observations. Many patients had high dependency personal care needs. This meant there were not enough staff available to support the other patients. Staff also reported that when staff were on breaks this also left the ward short of staff to support patients.

During our inspection, we saw a patient on Redwood ward was distressed and trying to get staff attention for periods of time, but there were no staff available to support them. There were frequent occasions when staff had to provide one to one support to this patient, but this had not been factored into the staffing establishment numbers on each shift. Staff told us the staffing establishment supported basic care and treatment and did not allow staff to spend time with patients to support with therapeutic activities which would benefit them. This concern was ongoing and had been discussed at the divisional governance meeting in May 2025 where it was recorded the staff were “exhausted and frustrated” and “only able to provide basic care needs such as support with meals, personal care and medication because of insufficient staffing numbers”.

Five patients had identified swallowing difficulties (dysphagia) and required additional support with their meals and when taking medicine. The qualified nurse responsible for administering medicines was spending in excess of 2 hours on this task each morning and this meant they had less oversight of the ward or time to spend with patients. On the first day of our visit the second qualified nurse was an agency nurse who did not have the required dysphagia training, so could not support with medicine administration. On our second visit there were 3 agency health care assistants who also had not received the required dysphagia training to support these patients with their meals and drinks, so this put additional pressure on other staff.

We used an observational tool (short observational framework for inspection) to observe the experiences of patients with dementia and communication difficulties to assess their quality of life, interactions and engagement. While we saw examples of good staff engagement, we also saw examples of staff not engaging with patients. Patients responded to regular staff who knew them well and how to engage with them in a positive way, however less so with agency staff they did not know. Some patients had limited interactions with any staff member.

There were no therapy staff such as psychologists and occupational therapists deployed at weekends and during the week there was limited access to occupational therapy assistants. Staff did not know what day to day support the ward would receive so staff could not plan activities to suit patients’ needs and preferences. Therefore, there was limited support for patients to engage in activities they were known to enjoy or to access leave outside of the ward environment.

Staff did not always have time to read care plans to ensure they were up to date with each patient’s current and changing needs.

Staffing concerns were identified at out previous inspection in March and April 2025. At this inspection we found the use of agency staff had reduced but concerns about staffing numbers remained. Minutes of ward meetings showed staff had continually raised their concerns about staffing. For example, meeting minutes recorded in May and June 2025 that patient safety was compromised because there were patients pacing the wards, invading other patient’s space, and at risk of falling. Staff said the ward felt tense and stressed, “an accident waiting to happen”. They said the quality of care was not good enough and there was no opportunity to engage with patients outside of basic tasks.

A review of staffing data from May to July 2025 showed that on Aspen ward, the proportion of shifts covered by qualified agency nurses decreased from 3.3% in May to 0.5% in July, while healthcare assistant agency staff usage dropped from 20.1% to 1.6% over the same period. Cherry ward also saw a decline, with qualified agency nurse shifts accounting for 1.1% in May and 3.5% in July, and healthcare assistant agency staff usage falling from 10.6% in June to 1.2% in July. On Redwood ward, the percentage of shifts filled by qualified agency nurses remained low, ranging from 2.2% to 0.8%, while healthcare assistant agency staff usage varied but peaked at 10.3% in July. Overall, these figures reflect a positive trend towards reduced reliance on temporary staffing solutions.

There were staff vacancies on Redwood ward for 2.3 whole time equivalent registered nurse posts, but the ward was fully recruited for deputy ward manager and above establishment for healthcare assistants and senior health care assistants. For Cherry ward there were no staff vacancies for any grade of nursing staff.

Staff sickness rates for Redwood ward were 3.6% in July 2025 and on Cherry ward 2.2% for the same period (this was below the national average of 5.6%). There was zero staff turnover (staff leaving) for Redwood and Cherry ward for the period May to August 2025.

Aspen ward had closed at the time of writing this report.

There were no concerns reported about access to medical staff.

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.