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

This means we looked for evidence that people were protected from abuse and avoidable harm.

During this inspection we considered how people were receiving services in line with Right Support, Right Care, Right Culture. At our last inspection of medium secure, and LD/A, 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 inspection identified concerns across multiple domains, with some improvements noted since the last review. While incident reporting and safeguarding training compliance had improved, persistent issues in staffing, communication, and risk management continued to pose serious safety concerns for patients and staff. A culture of openness and proactive safety remained inconsistent. Allegations of abuse by staff to patients was the highest category of safeguarding incidents. CCTV reviews revealed serious concerns including inappropriate restraint and assaults on patients by staff. Preventative actions had not always been taken to avoid incidents, leading to avoidable harm. We found 6 cases of staff asleep during enhanced observations, which was a serious patient safety risk. There was also a backlog of overdue incident reviews (LD/A wards: 1,600 in September), and lessons learned had not been consistently communicated across teams.

The service 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 service remain 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 listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

Staff told us managers had recently focused on staff recording of incidents on the system. All staff knew what incidents to report and how to report them. During inspection, we found that staff had reported incidents they should report in line with service policy. This was an improvement from our previous inspection.

Between 10 August and 10 October 2025, there were 696 incidents reported across the medium secure wards. Of these, 407 were rated as no harm, 253 as low harm, and 36 as moderate harm. The majority (555) were patient incidents, with 288 attributed to violence and aggression. There were 103 incidents involving staff. In the same period (10 August and 10 October 2025), there were 296 incidents reported across the LDA wards. Of these, 166 were rated as no harm, 108 as low harm, and 24 as moderate harm. The majority (258) were classified as patient incidents, with 190 attributed to violence and aggression, and 108 specifically to physical aggression and violence.

Incident trends on LDA wards showed notable fluctuations over the summer. The total number of incidents rose from 250 in June to 350 in August, before reducing slightly to under 300 in September. However, during this timeframe the number of restrictive interventions had increased. The use of force incidents had climbed to 160 in September (from 120 in June), and restraint episodes had risen to 140 (from 100 in June 2025).

The number of incidents which had not been reviewed by a manager and were overdue were also concern. In medium secure and LDA wards combined, overdue incidents increased slightly in August to over 300, before reducing to 250 in September. However, within LDA specifically, overdue incidents rose sharply from 1,000 in July to 1,600 in September, indicating a backlog that requires urgent attention. The number of overdue incidents in medium secure, LDA had increased slightly in August to over 300, however then reduced in September 2025 to 258. Failure by managers to review incidents in a timely manner increases the likelihood of recurrence, compromises staff and patient safety, and undermines organisational learning. Delays can result in incomplete investigations, missed opportunities for corrective action, and non-compliance with statutory and regulatory requirements.

On Fairbairn ward staff reported feeling supported in managing incidents, and there was improved communication and morale on the ward. We were made aware of 2 recent racially motivated incidents from patient to patient on the ward. These had been appropriately escalated to safeguarding. The two patients had been made aware that safeguarding reviews in relation to the racially motivated incidents were ongoing, although they were not aware of the safeguarding outcome in relation to the racially motivated incidents. However, some staff felt unsupported in relation to incidents. One staff member told us that managers had a ‘blaming way of addressing incidents.’ A second member of staff told us that incidents happened when staff were stretched, and another staff member told us an incident which had taken place on another ward had adversely affected staff morale on the ward.

Support for staff post incident had improved. We were informed that debriefs post incident and learning for incidents, including contributory factors, were now taking place.

The service had systems and processes in place for the sharing of learning from incidents. Staff we spoke with were aware of some lessons learned from recent incidents and could provide details of learning. For example, a staff member was able to describe an incident where a patient had removed screws from a light switch and was able to outline agreed actions. During our inspection we observed posters detailing lessons learned on the ward, and staff were able to provide us with details of learning. However, not all staff members had not been informed of a serious incident which had taken place on one of the wards. One staff member told us they had been informed of a serious incident which had taken place on one of the wards. However, another staff member told us that they knew some details but that this was just ‘hearsay’. Another staff member told us about an incident that had not been shared in the morning handover, whilst a further staff member advised that lessons learned were not being shared in the morning ‘huddle’ meeting.

Staff had not always taken required actions to prevent an incident from happening. We were informed a staff member had been seriously assaulted on the ward. Staff told us the patient had indicated prior to the incident they intended to assault the staff member. Staff told us these threats had not been taken seriously, therefore, preventative actions had not been taken, which could have prevented the incident occurring. Other examples included incidents taking place, when there were no staff in the vicinity, to de-escalate situations before they escalated.

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. However, we found improvements in this quality statement since our last inspection.

The service had referral and admission processes in place. This process aimed to ensure that all essential information about the patient was received to determine if the patient’s needs could safely be met. However, (due to current conditions being in place in relation to restrictions on admission), the service had only received one admission since the time of our last inspection in July and August 2025.

Staff planned patients’ discharge and worked with care managers, coordinators and where appropriate the ministry of justice, to make sure this went well.

Most staff knew about any risks to each patient and acted to prevent or reduce risks. To assist in the management of patient risk, staff undertook observations (enhanced support) of patients. The level of support across all wards ranged from general support, involving checks every hour, to continuous enhanced support within arm’s reach with up to 4 members of staff. Staff entered observation records onto an electronic tablet. Data was collated on a dashboard to enable senior staff to assess the compliance of observations with the policy. However, we were informed that due to connectivity issues with the Wi-Fi, that observations had to be recorded retrospectively on occasions.

Enhanced observations were generally undertaken in accordance with the organisation's policies and procedures. However, between the beginning of August and end of October 2025, there had been 6 incidents where observing nurses were found to be asleep whilst they were supposed to be continually observing a patient. This placed patients and staff at risk of assault or harm. The service had taken appropriate steps with the staff members to address the alleged poor performance of the staff members involved.

The service shared the medium secure observation audit results for August to October 2025. The audit demonstrated compliance with observation protocols, documented care plans, regular multidisciplinary reviews, and observation practices. However, areas for improvement included enhancing the detail and clarity of exit strategies from observations in care plans, to ensure that all MDT consistently review details and provide clear rationales for ongoing support. There was also a requirement for an increase in the variety of meaningful activities available to patients when on observations, and to continue to promote patient involvement in care planning, adapting approaches to individual needs and mental state. The audit showed that patient experience was generally positive, although the audit highlighted that there were opportunities to further strengthen care planning, activity provision, and documentation practices to ensure the highest standards of care across all wards.

The service told us there were no observation audit results available for the LDA division due to large amounts of annual leave during August and September. There was an assessment in place to review the observation audit to make it ‘more dynamic'.

Staff involved all the necessary healthcare and social care services to ensure patients had continuity of safe care, both within the service and post-discharge.

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 received training on how to recognise and report abuse, appropriate for their role. Staff knew how to make a safeguarding alert and did so when appropriate. Between 01 August and 28 September 2025, 122 safeguarding incidents and concerns were recorded for the medium secure division. Of the incidents recorded, 99 safeguarding’s were recorded as a low level concern, which did not meet threshold for reporting to the local authority. The remaining 23 incidents were referred as safeguarding concerns to the local authority. The severity of the 23 safeguarding incidents included 15 low harm or no harm incidents (Level 1 and 2) and 8 moderate harm (Level 3). Eight of the 23 safeguarding concerns were closed at referral stage with an outcome of ‘no further actions required, and 4 incidents required section 42 enquiries to be conducted by the service. A Section 42 enquiry is an investigation by a local authority to determine if an adult is at risk of, or experiencing, abuse or neglect, which is a legal duty under The Care Act 2014. The remaining 9 Section 42 enquiries were being undertaken by the local authorities’ safeguarding team.

For the same period (01 August and 28 September), 130 safeguarding incidents had been raised across LDA wards. Of the 130 incidents reported, 65 (50%) were rated as no harm, 36 (28%) low harm and 29 (22%) medium harm. Violence and aggression accounted for most incidents (71 cases, over 50% of total), signalling a significant risk.

Staff were kept up to date with their safeguarding training. As of September 2025, the training completion rate for safeguarding level 3, across medium secure wards was 100%, and across LDA wards was 99%. Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act.

Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies. However, the service had not always protected patients from abuse. The highest number of safeguarding incidents across the medium secure wards (8) related to allegations of abuse by staff to patients. This was followed by 4 security incidents, 3 physical violence and aggression, and 2 accident and injuries. One referral was made in relation to each of the following: medication, clinical equipment failure, verbal aggression and service failure.

The highest number of safeguarding incidents across the LDA wards (21), related to allegations of abuse by staff to patients This was followed by self-harm (18) and violence and aggression (11).

The distribution of harm levels across LDA wards showed that while most incidents resulted in no or low harm, nearly 30 incidents were medium harm, which was concerning for patient safety. Categories such as self-harm and sexual safety highlighted ongoing risks and vulnerabilities among patients.

Some patients told us that they did not feel safe on the wards. Three patients told us that had been bullied by co-patients. Patients also told us that they had witnessed other patients being racist toward staff members.

Staff demonstrated an understanding of which incidents required reporting and the correct procedures for doing so. Managers ensured that all reported incidents (once they had been initially screened), were investigated thoroughly.

A review of the incident analysis meeting covering the period from August to October 2025 showed that, across the LDA wards, nine incidents had been reviewed under the patient safety incident investigation process. These included 5 incidents involving harm to patients while under enhanced observation, 3 incidents related to security breaches and searches and 1 incident concerning restraint and seclusion. During the same timeframe, five incidents on the medium secure wards were identified for further review. Of these, 1 involved harm to a patient while being supported under enhanced observation, 1 was a medication management issue, 1 was a security incident and 2 were categorised as ‘other’, relating to a patient throwing a hot drink over a staff member and an incident of restraint and seclusion.

During our inspection, we reviewed CCTV footage relating to 16 incidents: 10 from medium secure wards and 6 from LDA wards. Of the 10 incidents in medium secure wards, concerns were identified in 2 cases AND across LDA wards, concerns were raised in 5 cases. The concerns identified included delays in the removal of a ligature, 2 instances of patient assault by staff, inappropriate restraint, a staff member covering a patient’s mouth during restraint, and a staff member observed pulling a patient. As part of the agreement with the CQC, the provider had a process in place for the review of incidents, and actions had been taken where appropriate.

We found that several restrictions remained in place which were blanket restrictions. These included all patients not having access to hot water to make a hot drink, not freely access to cold drinks and snacks. Staff told us that the lack of access was due to individual patient risk. During inspection we reviewed patient records and noted that these restrictions had not been care planned. Any restriction implemented to address patient risks, should be individually risk assessed and care planned, and the restrictions implemented should not adversely affect other patients on the ward.

Staff followed safe procedures for children visiting the service. Any child visits were held off the wards.

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.

Staff completed risk assessments for each patient on admission, using a recognised tool, and reviewed this regularly, including after any incident. All patients received a comprehensive risk assessment on admission to the ward, which was updated regularly.

Most staff demonstrated an awareness of individual patient risks and took measures to prevent or reduce these risks. At the start of every shift, staff attended a handover meeting to share essential information. However, information was not always effectively communicated. For example, the minutes of the women’s secure services clinical governance meeting, September 2025, states that on Bracken ward ‘handovers are an issue, not consistent in accurate handovers, communication book to be used at all times.’ In addition, some staff told us that key information had not always been communicated effectively.

Each ward held a daily safety huddle (Monday to Friday), where staff discussed key clinical updates, recent incidents, and any physical health concerns. These meetings provided an opportunity for staff to identify emerging issues and agree on immediate actions. Any concerns raised during the ward-level safety huddles were escalated to the service-wide safety huddle, with the aim of ensuring that risks were addressed promptly and at the appropriate level.

The numbers of restrictive interventions including patient restraints had increased. Staff told us that they attempted to avoid using restraint by using de-escalation techniques and restrained patients only when these failed and when necessary to keep the patient or others safe. Staff told us that restraint was only applied when these strategies were unsuccessful and when necessary to ensure the safety of the patient or others. However, levels of restraint, rapid tranquilisation, seclusion and long-term segregation varied across the service. Between August to September 2025, across the LDA wards the number of restraints was 160 (September 2025). This was a gradual increase from 120 (June 2025). Of these, 18 incidents (2%) involved the use of prone restraint. 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. It includes being placed on a mattress face down while in holds; administration of depot medication while in holds prone, and being placed prone onto any surface. The reasons given by the provider for restraining patients in the prone position across the LDA wards were as follows: administration of rapid tranquillisation: 2 cases, care planned intervention: 1 case, patient position at the time of the restraint: 11 cases, other (reason not indicated): 2 cases. During the same period, 95 restraints were recorded across the 9 medium secure wards, of which 3 involved prone restraints. In all 3 cases, the use of prone restraint was attributed to the patient’s position at the time of the intervention. The number of seclusions was 49 (of which 48 took place in the seclusion room and 1 in another area of the ward). During the same period, there were 58 incidents of rapid tranquillisation and 15 incidents of long term segregation.

For the same period (August to September 2025) across the medium secure wards, there had been 95 restraints. This included 3 prone restraints. The reason given for use of prone restraint was given as the ‘patient’s position’. During this period the number of seclusions were 10, rapid tranquillisation 20 and long term segregation 8.

Staff usually adhered to national guidance when administering rapid tranquilisation. Following its use, patients were placed on enhanced observations to ensure their safety. Staff carried out checks of the patient’s vital signs after rapid tranquilisation, providing close monitoring and timely intervention if required.

Levels of restrictive interventions were monitored closely by managers. Across all wards, there were 78 episodes of rapid tranquillisation between beginning of August and end of September 2025. This included 20 episodes of rapid tranquillisation in medium secure wards and 58 episodes in LDA wards.

When a patient was placed in seclusion, staff kept clear records and followed best practice guidelines. During the period beginning of August to the end of September 2025, there had been 58 episodes of seclusion. Of the 58 episodes of seclusion, 10 had taken place in medium secure wards and 48 in LDA wards. The data suggests that seclusion was used significantly more frequently in LDA settings, which aligns with the overall trend of increased incidents and restrictive interventions in these wards.

Staff enabled patients to give feedback on the service they received (for example, via surveys or community meetings). In October 2025, all patients across the medium secure wards were invited to participate in the “My Voice” survey. A total of 42 patients completed the survey representing a broad cross-section of wards including Mackaness, Maple, Cranford, Prichard, Bracken, Willow, Robinson, Rose, and Fairbairn. Of the responses received, half (50%) were positive, with patients expressing satisfaction with aspects such as staff kindness, feeling cared for, and the support provided. Around 29% of responses were negative, highlighting areas of concern. The themes relating to ‘what we can do better’, related to staff and support. The issues raised under ‘staff’ included care, treatment, more staffing, restrictions, more appointments, more understanding of conditions and communication. The issues raised under support included listening, consistency, leadership, starting a LGBT group. The remaining 21% responses were neutral.

The service conducted enhanced support observation audits. The enhanced support audit for medium secure (August to October 2025), demonstrated that care plans generally documented patient involvement and the rationale for enhanced support, although the detail of exit strategies varied. Gender-specific support and privacy considerations were addressed where relevant. Weekly multidisciplinary reviews were evident in most cases, with participation from multiple professionals and documentation of progress against care plans. Observation records were completed in line with prescribed enhanced support levels and typically contained sufficient detail regarding patient risk, engagement, and behaviours. Enhanced support was mostly provided as planned, and activity sessions were observed with evidence of engagement. However, some audits noted that the range of activities offered was limited. Feedback from patients was mixed: while some individuals expressed satisfaction with staff interactions and observation arrangements, others declined to comment or were unavailable during the review.

Staff ensured that patients could access advocacy. However, the service had recently changed their advocacy service. Staff told us that consequently access to independent advocacy had decreased.

During our inspection, we reviewed 20 patients’ clinical records plus 20 personal behavioural (PBS) support plans. All patients had positive behaviour support (PBS) plans in place. Most PBS plans contained spelling and grammar errors and were not consistently written in the first person, with some using third person language instead. Additionally, some plans included inappropriate terminology, such as references to ‘having a nice attitude’ and ‘wanting attention’ While the plans were comprehensive, their length raised concerns about how quickly staff could access key information during a crisis. Staff did have access to laminated PBS summary (grab sheets), however, these were not always dated or kept up to date.

Across the wards there were 15 people being cared for in long-term segregation (LTS). The CQC have conducted recent Independent Care (Education) and Treatment Reviews (ICETR). ICETRs are in-depth, independent reviews of the care and treatment of people with a learning disability and/or autism who are detained in long- term segregation (LTS). They were introduced as part of NHS England’s commitment to improve care quality and reduce restrictive practices. The outcome of ICETRs identified several shortfalls. For example, a recent ICETR in relation to a patient originally from Fern ward, identified concerns in relation to the patient’s physical health, mental health, medicines, quality of life and safety and risk. Serious concerns were identified in relation to the person’s experience. An action summary to address identified areas of concerns, has been shared with the service, with a completion date of the end January 2026.

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 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.

Managers had calculated the number and grade of nurses and healthcare assistants required. The total funded establishment for medium secure wards was 322 WTE (whole time equivalent). This was comprising of 69 WTE qualified staff and 253 WTE unqualified staff. As of October 2025, there were 61 WTE qualified staff (8 below funded establishment) and 229 WTE unqualified staff (24 below funded establishment). The total funded establishment for LD/A wards was 349 WTE, of which 72 WTE posts were for qualified staff and 277 WTE for unqualified posts. The number of qualified staff in post as of October was 80 WTE qualified staff (8 WTE above funded establishment and 287 WTE unqualified staff (10 staff members above funded establishment). However, staff were often moved wards to ensure adequate cover.

The service did not always have enough nursing and support staff to keep patients safe. The service had not ensured there were enough qualified, skilled and experienced staff on the wards. We were not assured that staffing levels were sufficient to meet patients’ needs or keep them safe. Patients and staff at all levels spoke to us about their concerns regarding staffing levels. This was an indication that the current funded establishment did not meet the need of the service.

The service had reducing vacancy rates. This was mainly due to ward closures. The total number of vacancies across the medium secure wards in October 2025, was 29. This was mostly due to unqualified staff vacancies (under established by 31 WTE). There was 0.5 of a WTE vacancy for registered nurses. Bracken was the only ward over established (by 1 WTE). Overall, there were no vacancies across the LDA wards. The division was over established by 7 registered nurse and 9 senior HCAs but were under established by 6 HCAs. Overall, the service was over establishment by 10.46 WTE. Oak ward had the highest number of staff over establishment with an additional 9.5 staff in post, followed by Sunley with 6 WTE over establishment. The only ward under establishment was Berry which overall had a vacancy factor of 2 WTE.

Patients did not always have access to activities such as psychology sessions, art, and physical exercise. Staff and patients told us that activities and leave were often cancelled due to low staffing levels and, especially when covering for staff breaks. Some patients told us that they had to get up early in the morning to be able to have leave, as after staff breaks have been arranged, there was no possibility of them getting off the ward due to a lack of staff availability. One patient told us that that patients couldn’t access leave in the afternoon, due to staff breaks. Numerous staff members told us that due to low staffing levels, they could either maintain the safety of the ward (including staff visibility in the lounge and bedroom corridor) or promote meaningful activities to promote safety on the ward, but not both. Some patients told us that staff were often not present in main ward areas.

One staff member told us that the lack of staff was “adversely affecting the mental health of staff”. This view was supported by another staff member who advised that staff feel unsafe. This view was shared by a further staff member who told us that staff “feel at risk”. Another nurse told us that “staff numbers are the biggest issue”, adding “I can’t remember the last time I could sit and talk to patients”.

There was adequate medical cover day and night and a doctor could attend the ward quickly in an emergency. However, staff and patients told us that due to consultant psychiatrist vacancies, there had been high number of different locum psychiatrists. One senior staff member told us that “there have been lots of changes in responsible clinicians. I feel for patients”.

When necessary, managers deployed agency and bank nursing staff to improve staffing levels. The average percentage of shifts worked by temporary staff across the medium secure wards was 22% in August, and 16% in September. The highest percentage use of temporary staff in August was Cranford (28%) and the lowest Rose (14%). The highest percentage use of temporary staff in September was Maple (25%), and the lowest percentage was Rose (10.5%). However, not all bank staff were adequately trained to work on the wards. The minutes of the LDA clinical governance meeting (September 2025) states that work choice (the service’s bank), were sending bank ‘staff onto nights that are not skilled, i.e. staff report they are unable to complete Rio progress notes or audits etc’. This presented a risk that the nurse may be unaware of the patients’ needs and that essential information may not be documented in the patient’s record.

There were enough staff in the service to carry out physical interventions (for example, observations, restraint and seclusion) safely (and staff had been trained to do so), however this was a cost to patient activities. Staffing levels allowed patients to have regular one-to-one time with their named nurse. Of the 48 staff members interviewed, 29 staff members (60%) and 13 out of the 35 patients interviewed (37%), told us that staffing levels were not adequate to meet the needs of the patients.

Between August and October 2025, there were 46 staff injuries across the medium secure wards, of which 43 related to violence and aggression and 3 related to accidents and injuries. Of the 46 staff injuries, 44 were rated as low level and 2 rated as moderate level harm. The highest number of staff injuries (15) was on Bracken ward, followed by Maple (11). There were no staff injuries reported on Rose and Fairbairn wards. During the same period (August to October 2025), there were 165 staff injuries across the LD/A wards of which 162 related to violence and aggression, 5 related to accidents and injuries and 1 related to a fall. Of the 165 staff injuries, 158 injuries were rated as low level and 7 rated as moderate level harm. The highest number of staff injuries (119) was on Oak ward, followed by Marsh (16). There were no staff injuries on Berry ward.

The total hours lost to work related injury, was 1,177 hours. This equates to roughly 32 weeks of work lost (based on a 37-hour week). In September 2025, medium secure wards reported an average sickness level of 9%, which was slightly above the service’s target of 8%. Injury-related absences accounted for 1,177 hours lost, equivalent to approximately 32 weeks of work, which represents a significant impact on staffing capacity.

The staff sickness and absence rates varied across the services. The average sickness level (Sept 2025) across the medium secure wards was 7% (1% below the service’s target of 8%) Injury-related absences across the medium secure wards, accounted for 213 hours lost. Of these, 33 were due to violent incidents, 26 due to injuries caused during a restraint with 20 incidents being classified as an industrial injury. The highest number of injuries to staff took place on Bracken, Mackaness and Maple wards each reporting 5 staff injuries. The highest number of hours lost (129) was on Bracken ward.

The average sickness level (Sept 2025) across the LDA wards was 8%. Across LD/A wards, injury-related absences accounted for 1,177 hours lost, which roughly equates to 32 weeks of work lost (based on a 37-hour week), which represents a significant impact on staffing capacity. Of the incidents which resulted in staff injury, 33 were due to violent incidents, 26 due to injuries caused during a restraint, with 60 incidents being classified as an industrial injury. The highest number of injuries to staff took place on Oak ward. This resulted in 699 staff hours lost to staff injury.

The average turnover rate for LDA wards between August and October 2025 was 1.64%. The turnover rate by month, had decreased from 2.5% in August, to 0.73% in October 2025. The average turnover rate for medium secure wards between August and October 2025 was 1.42%. The turnover rate by month had increased from 0.72% in August, to 2% in October 2025. At the time of our inspection, the provider were not able to admit any patients without the approval of the CQC. In response some wards had closed, and the service had a voluntary redundancy process in place. This had resulted in a reduction in the use of agency staff. The voluntary turnover in October 2025 was 1%.

Managers monitored mandatory training and alerted staff when they needed to update their training. Managers received a regular report showing compliance with mandatory training requirements. The mandatory training programme was comprised of 12 training courses including immediate life support, infection control, relational security and safeguarding. Training for agency staff was delivered by the relevant agency.

Staff were up-to-date mandatory training, with an overall compliance rate of 91% across the medium secure wards and 95% across the LDA wards. Within medium secure wards, Pritchard ward achieved 100% completion across all courses, demonstrating compliance. However, some gaps were noted: basic life support training on Willow ward was the lowest at 84%, and restraint training compliance was 88%, with outstanding staff already booked to attend sessions.

Across LD/A wards, the lowest mandatory training rates were observed for basic life support, with Marsh ward at 58% and Sunley ward at 64%. The service advised that these low compliance figures were primarily due to staff members who had failed the course and were then required to re-sit (rather than non-attendance or lack of engagement). Figures shared by the service showed that outstanding staff were already booked to attend these training sessions.

The service maintained a list of 18 non-mandatory training courses, covering both clinical topics (such as seclusion and enhanced support) and non-clinical areas (including food hygiene and health and safety law). Across the medium secure wards, compliance was generally strong, with 6 out of 9 wards achieving rates above 83%. However, gaps were identified in specific modules. For example, clinical manual handling compliance was 68% on Cranford ward, while dysphagia training compliance was 66% on Cranford ward.

Compliance rates for non-mandatory training across LDA wards varied considerably. While Berry, Brook, and Fern wards achieved compliance rates above 86%, notable gaps were observed in specialist courses. Dysphagia training compliance was 70% or below on Acorn, Marsh, Meadow, Sunley, and Sycamore wards, with Sunley ward recording the lowest rate at 53%. Similarly, self-medication management training compliance was 62% or below on Acorn, Oak, and Sycamore wards.

These findings highlight that while overall compliance is positive in some areas, there were gaps in critical clinical training such as dysphagia, manual handling, and risk assessment. Addressing these gaps is essential to ensure safe and effective care, particularly for patients with complex needs.

As of September 2025, 100% of staff across the medium secure and LDA wards had attended training in learning disabilities and autism. The service had introduced SPELL training (the National Autistic Society’s framework for understanding and responding to the needs of autistic people), in October 2025. As of October 2025, the service had trained 7 staff to facilitate the in-house training. At the time of our inspection, across the LDA division, 29 staff had completed this training. In addition, a staff member from Berry and Marsh together with 26 occupational therapists had attended sensory training. The aim of this training is to ensure all staff understand how patient process sensory information, to enable staff to safely and effectively apply strategies, to support patients’ regulation, wellbeing, and engagement.

As of 10 October 2025, the average clinical supervision rate for medium secure wards was 94%. Mackaness, Robinson, Rose and Maple achieved full compliance (100%), while Cranford ward reported the lowest rate at 81%.

Management supervision compliance varied significantly. The average compliance rate for medium secure was reported at 95%, with 77% of records achieving full (100%) compliance. The compliance rate for LD/A wards showed an average of 69%, with only 40% achieving 100% compliance. The lowest compliance rates were observed on Sunley ward (65%), LDA social work (50%), and Fairbairn ward (35%), highlighting variation across teams.

The average staff appraisal rates for medium secure wards as at end September 2025 (88%) and LDA wards (92%). Across medium secure wards, Bracken, Cranford, Prichard and Rose achieved 100% compliance. The lowest percentage compliance was Fairbairn ward (35%). Across LDA wards, Acorn, Berry, Brook, Meadow and Oak wards achieved 100%. The lowest appraisal compliance rate in LDA was Marsh (67%) and Sunley (68%).

On Fairbairn ward (specialist ward for deaf patients), there had been an increase in the number of staff who had commenced British sign language (BSL) training. A new ward manager was in post who could sign, and the use of sign language on the ward had improved following our last visit. However, there was still a lack of BSL interpreters. Patients and staff told us that there was not always access to interpreters. Staff could request access to interpreters via a booking system; however, interpreters were not always available. According to ward staff there was a lot of unfilled gaps. On the day of our inspection the fill rate for interpreters was 33%.

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.