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.

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. Systems for learning from incidents and using that learning to improve practice were not consistently effective. Although risk assessments were in place, care records did not always include enough details to clearly guide staff, and daily records often focused on tasks rather than how care was tailored to the person. We identified ongoing concerns in how risks were managed, including safeguarding practice, which meant people were not always protected from avoidable harm.

Staffing pressures continued to affect the service. The provider continued to rely on bank staff to fill staffing gaps, and this did not always provide stable or sustainable cover. In some cases, this led to people experiencing delays or cancellations to planned leave or activities. While staff worked hard to support people, these pressures meant people were not always able to access the care and opportunities they were entitled to.

However, we saw some improvement since the last inspection. The provider had taken steps to remove some blanket restrictions that was identified in previous inspection, and restrictive practices were more often individually assessed rather than applied to everyone. Documentation around incidents and injuries had improved, and staff demonstrated an understanding of safeguarding processes.

The service was previously in breach of the legal Regulations in relation to safe care and treatment (Regulation 12), safeguarding service users from abuse (Regulation 13), and staffing (Regulation 18). The provider remained 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 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 and report safety events. Lessons were not learnt to continually identify and embed good practice.

The service had processes in place to enable staff to report incidents and support learning from investigations. Staff shared learning through ward team meetings, daily huddles and governance meetings, where incidents, safeguarding concerns and operational risks were discussed. Meeting records showed that learning from incidents was included on agendas and actions were sometimes agreed. However, the processes were not used consistently and effectively, and learning was not always translated into changes in practice.

Learning was shared through daily huddles, staff meetings, handovers, reflective practice sessions and reminders through email or verbal updates. Some meeting records we reviewed showed follow-up on actions from previous huddles, including updates on completion or ongoing work, particularly in relation to estates issues, staffing levels and environmental concerns. However, actions were not always recorded with clear owners or deadlines, and follow-up was not always documented in later meetings. In one ward governance meeting we reviewed, we saw inconsistent recording of incident data was noted, where reported reductions in restraint were not aligned with the figures described in the accompanying information.

The provider used lessons learned documents and learning alerts to communicate learning from incidents. Five lessons learned documents were reviewed, covering areas such as medication safety, falls management, transfers from acute hospitals, use of physical intervention and environmental safety. The learning documents described what had gone wrong and highlighted key risks, but actions were often focused on individual staff behaviour and were not consistently supported by named ownership, review dates or checks to confirm that learning had reduced risk over time. We reviewed examples that focused on maintaining clutter-free airlock areas to support safe patient transfers. The alerts also identified concerns regarding the inappropriate use of patients’ towels and blankets by staff during night shifts within some areas of the charity. Staff were reminded to stop this practice immediately and were encouraged to raise concerns through appropriate channels, including the Freedom to Speak Up (FTSU) process. Another alert reviewed evidenced examples such the safe disposal of used ampoules, missed medication doses following return from acute hospital admission, and undetected injuries following falls. The alerts highlighted the importance of checking discharge summaries, following post-fall monitoring guidance and ensuring staff understood safe medication practices.

Staff understood how to report incidents and used the incident reporting system, and a wide range of incidents were logged across the service. We spoke with 23 staff during our inspection. Only 8 of the 23 staff interviewed (34.8%) were able to clearly describe a recent example of learning from incidents and explain how this had resulted in changes to practice. Some staff could not confirm if an incident the previous day, resulting in patient injury had been handed over to them. While some staff were able to describe actions taken following incidents, most staff were unable to clearly explain how learning from incident reviewed had resulted in changes to practice or reduced risk. Patients were able to express their views in community meetings and through other staff engagement channels, and while the service had taken actions to resolve some concerns raised by people, there were issues that remained unresolved. Three recent incidents reviewed showed that lessons learned had not been effective in practices especially in reducing the reoccurrence of patient-to-patient safeguarding issues, and in poor safe holding practice by staff during physical restraints.

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.

At the last inspection, CQC placed conditions on the providers registration which prevented them from admitting new patients, this remained in place at the time of this inspection.

On the 5 wards we visited, staff told us there had been no new external admissions to the service. However, during the period reviewed, 6 internal patient transfers took place between acquired brain injury (ABI) wards, with all transfer occurring within the ABI division. Of the 6 patients transferred across the division, 5 were moved from the closed Church ward and one was transferred from Tallis ward to Tavener ward in line with their planned care pathway.

Staff described that admissions would usually be planned, with relevant multidisciplinary team members completing an initial assessment and sharing key information (including care plans, positive behaviour support plans and risk documents) with the ward team in advance.

Staff worked together to create time to review care plans, including swapping tasks where needed. Information was also shared through daily huddles, pre-admission assessments completed, progress notes and care plans collected from the referring ward.

The service worked with external partners to plan admissions and transfers, and multidisciplinary teams assessed whether patient needs could be met safely.

The service had not used agency staff during the period reviewed but continued to use bank staff to support staffing levels. While staff told us this helped maintain cover, it did not always support continuity of care. Records showed that senior staff monitored observation practice, but this did not always prevent delays.

On one ward, we identified delays in the completion of general and enhanced observations for 4 patients. Some entries were recorded as missing or not yet entered. We saw examples where observations required every 15 minutes were recorded 28 and 29 minutes late, and observations required every 30 minutes were recorded 41 minutes late. In other instances, observations required every 60 minutes were recorded up to 80 minutes late, including on 21 October at 14:00 and on 22 October at 11:00. One staff member told us they were completing intermittent observations while also supporting breakfast and were trying to catch up. These delays reduced assurance that patients were consistently monitored in line with their care plans and the service observation policy.

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 understood how to raise safeguarding concerns and used internal electronic reporting systems. The provider had safeguarding policies and procedures in place which reflected statutory guidance and outlined staff responsibilities and escalation pathways. Safeguarding concerns were reviewed through ward and divisional governance structures. Staff were aware of how to escalate concerns internally and to the local authority where required.

Staff were trained in safeguarding and could explain how to escalate concerns. Compliance with safeguarding training was consistently above 95% across all wards. Despite this, safeguarding processes were not always robust. Three carers across the wards reported recurring safeguarding concerns and poor follow-ups. These concerns included allegations of staff abuse, patient-on-patient assaults, delays in wound care, and issues relating to medicine management.

The service had put plans in place to reduce the risk of avoidable physical assaults; however, these measures had not always been effective in mitigating ongoing risks, which meant people remained at risk of avoidable harm. In the last 3 months, from August to October 2025, the service recorded a total of 168 safeguarding concerns across the ABI wards inspected. Of these, 24 concerns (14.3%), met the threshold for referral to the local authority. The remaining 144 concerns (85.7%) were assessed as low-level concerns and did not meet the threshold for reporting to the local authority.

We reviewed 24 Section 42 enquiries. 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. At the time of the inspection, 12 of these had been closed and 12 were still open. Some referrals were closed quickly because the local authority decided no further action was needed, while others were investigated and completed by the provider or the local authority. The referrals that remained open were still being investigated or were waiting for formal outcome letters. Most of the concerns involved low or moderate levels of harm, and there were no cases of serious harm identified in the information we reviewed. Fifteen of the safeguarding referrals were assessed as low level or no harm. The remaining 9 referrals (37.5%) were assessed as involving moderate harm. There were no high-harm safeguarding incidents identified in the data reviewed.

Safeguarding referrals made to the local authority covered a range of concerns across the 5 wards. Of the 24 Section 42 enquiries, the most common reason was physical aggression or violence, accounting for 9 referrals (37.5%). Allegations of abuse involving staff and patients accounted for 5 referrals (20.8%), while injury or physical health concerns accounted for 4 referrals (16.7%). Other referral reasons included medication-related concerns (3 referrals, 12.5%), and single referrals relating to verbal aggression, security concerns, and self-harm (each representing 4.2%). This showed that safeguarding concerns most often related to physical safety, behaviour that placed people at risk, and the quality of care provided.

The provider recorded safeguarding concerns across all wards. Recurrent themes included unexplained injuries, physical altercations between patients, restraint practices, observation arrangements, delayed escalation of concerns, and allegations relating to staff conduct. Incident records showed that some patients were involved in physical confrontations that resulted in injury and required restraint and medical assessment. These incidents were recorded as both patient safety incidents and safeguarding concerns, reviewed through internal processes, and escalated to the local authority where appropriate. Although safeguarding processes were in place and used, repeated themes across incidents and referrals indicated that these systems were not consistently effective in preventing harm or achieving sustained improvement.

In the 2-month divisional key performance indicator (KPI) data reviewed, incident volumes and restraint episodes increased significantly (485 to 1,021 incidents and 121 to 203 restraints) while occupancy declined.

We also reviewed 125 incidents that were initially recorded as patient safety events but were later escalated to safeguarding following further review, including CCTV analysis and clinical review.

Of the 125 incidents reviewed, 6% flagged as safeguarding concerns, 62% were reported as risk reduced, 18% as risk removed, 5% as unknown risk, 2% as risk remained, and 11% as no risk. Types of safeguarding issues include physical, psychological, and financial/material abuse, as well as neglect and acts of omission.

This included incidents involving restraint, falls and prolonged management of patients in communal areas, as well as patient-on-patient altercations where risk mitigation strategies had not prevented recurrence. Records showed that staff completed incident forms and safeguarding documentation and escalated concerns in compliance with the provider’s policy. However, we found repeated themes involving patient-to-patient aggression and distress across wards, which raised questions about whether learning from safeguarding incidents was consistently embedded to reduce future risk.

Staff told us restraint was used as a last resort. Data showed that restraint was used in a proportion of incidents involving physical aggression, while seclusion was rarely used. Restrictive practices, such as access to outside areas and use of specific controls, were logged and reviewed.

Additionally, the use of a safety smoking jacket was not recorded in the care records of 3 patients. This meant there was no documented evidence that patients or their carers had been involved in discussion about how this measure was used to keep them safe.

Staff completed Mental Capacity Act assessments when people’s ability to make specific decisions was in doubt, and we saw examples of capacity assessments and best-interest decisions recorded in care records and discussed at multidisciplinary meetings. However, the quality of recording was variable. Some assessments lacked detail about how people were supported to make decisions, and there was limited evidence that capacity decisions were routinely reviewed following changes in presentation or incidents.

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.

We reviewed 27 care records where risk assessments were in place and up to date. However, documentation did not consistently evidence people’s views or demonstrate how risks had been discussed with them in a meaningful way. In several records, risk management plans focused on staff actions rather than shared approaches to managing risk, and patient voice was limited or absent. Where people had communication needs, there was inconsistent evidence that accessible tools or communication aids were used to support involvement in decisions about risk.

We found examples where risks were known but not clearly explained or documented through care planning. One patient’s care record showed a patient was regularly supported by a high number of staff during personal care and periods of distress. However, the care plan did not clearly document the rationale for this level of support or evidence that the patient had been involved in discussions about how risks would be managed. Similarly, on another ward, a patient’s voice was absent in their care plan regarding their preference during physical intervention.

Carers and relatives told us they were sometimes involved in discussions about risk and care planning, particularly following incidents. Some carers said staff listened to them and responded to concerns. However, others raised concerns about unexplained injuries, delays in being informed about incidents, and a lack of clarity about how risks were being managed following safeguarding reviews. Documentation did not always evidence how carers’ views were incorporated into revised risk management plans or how feedback was shared with the wider staff team.

Staff told us they understood the importance of risk assessments and described completing risk assessments, positive behaviour support plans and care plans upon admission and reviewing these at multidisciplinary team meetings. Staff were able to explain how risks such as falls, aggression, self-injury and physical health deterioration were identified and monitored. However, while staff could describe the processes in place, they were not always able to explain how people and carers were actively involved in shaping or reviewing risk management plans, or how learning from incidents informed changes to individual risk strategies.

Incident data showed that restrictive interventions and safety-related incidents occurred regularly during the period reviewed. A total of 2,040 incidents were recorded between August and October 2025, of which 18.5% involved restraint and 0.2% involved seclusion. Of the incidents recorded, 44.2% occurred in August and 55.8% in September, with no incident recorded in October within the data provided. All incidents during August and September related to patient safety. No prone restraint was reported during the period reviewed. We were informed that not all wards had closed-circuit television (CCTV) coverage at the time of the assessment; however, staff facilitated access to a sample of footage which we reviewed. This identified areas of concern, including the use of a non-approved safe intervention technique. Following this, the provider updated the patient’s care records, and the senior Safe Intervention Training (SIT) instructor, who had been involved in the restraint, identified further training actions to address the issue. While the provider continued to report restrictive interventions, we also continued to receive related concerns since the last inspection, demonstrating that previously identified risks had not been fully mitigated.

Most incidents resulted in no or low harm; however, the frequency and nature of incidents highlighted ongoing risks. Overall, 86.6% of incidents resulted in no harm, and 11.1% resulted in low harm. A smaller proportion led to moderate harm (2.3%), and a very small number resulted in catastrophic harm (0.05%). The most frequently reported incidents related to falls, physical aggression and violence towards staff or other patients, self-harm (such as head banging), and physical health accidents and injuries.

Falls were the most reported incident type. There were 1,144 recorded falls during the period reviewed. Nearly all falls (97.5%) resulted in no harm, while 1.9% resulted in low harm. Only 0.2% resulted in moderate harm.

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 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.

The provider had systems in place to plan, monitor and review staffing levels. However, workforce pressures meant there were not always enough staff to provide safe and consistent care.

In August, the service had a total staffing establishment of 242 whole time equivalent (WTE post across the 5 ABI wards. This comprised 40 WTE on Walton, 48 WTE on Allitsen, 24 WTE on Tavener, 59 WTE on Tallis, and 71 WTE on Elgar.

The total number of vacancies for qualified and unqualified staff across the acquired brain injury wards in August 2025, was 44.7 WTE. This was mostly due to unqualified staff vacancies at 36.7 WTE, and registered nurse vacancies at 8.0 WTE. Elgar ward had the highest level of vacancies at 18.3 WTE healthcare assistants and 3.4 WTE for registered nurses., Allitsen ward had 1.3 WTE registered nurse vacancies and 6.4 WTE vacancies for healthcare assistants to meet patient acuity and enhanced observation needs. Tallis ward had 5.3 WTE healthcare assistants vacancies and 2.0 WTE registered nurse vacancies. Walton ward had 5.4 WTE vacancies for healthcare assistants, while Tavener ward had the lowest vacancy rates overall, with 0.2 WTE registered nurses and 1.3 WTE healthcare assistants.

Staffing fill rates across the ABI wards remained high across on day shift in August and September 2025.In August 2025, the overall average fill rate was approximately 98.3% across the ABI wards. In September 2025 the overall average fill rate of approximately 99.1%. Therefore, shifts were largely covered despite underlying vacancy positions.

Across the 5 ABI wards, bank staff use reduced over time, from around 15.75% in August,16% in September, and 11% in October, while agency staff reduced from 2.42% in August to 0.26% in September and 0% in October.

A review of night‑time staffing in August 2025 showed that, although overall shift fill rates were reported as high, staffing was not consistently maintained across the full night shifts. On 20 nights in August 2025, wards including Allitsen, Tallis and Elgar recorded staffing below the required level, with reductions after midnight, and there were also periods where actual staffing was not recorded. Walton and Elgar wards demonstrated the most significant gaps in staffing records. Walton ward had 3 occasions where no staffing records were available, Tallis and Elgar wards had 4 days where staffing was not recorded. Other wards generally met planned levels but still demonstrated occasional shortfalls or post‑midnight reductions.

Ward managers told us they had calculated the number and grade of nurses and healthcare assistants required for each ward and reviewed this daily in response to patient acuity, dependency and enhanced observation requirements. Managers confirmed they could adjust staffing levels and redeploy staff between wards when needed, overseen by managers on call. When bank staff were used, managers aimed to use regular bank staff who were familiar with the service, and staff confirmed that bank staff received a local induction before working on the wards.

On the day of inspection, observed staffing generally matched or exceeded planned rotas. For example, Walton ward had 3 registered nurses and 9 healthcare assistants on the day shift for 12 patients, with one registered nurse and 5 healthcare assistants at night. Tallis ward increased the number of healthcare assistant above the usual level so there were enough staff to closely support 6 patients who needed enhanced observation. However, on Allitsen ward there were discrepancies between staffing boards, paper rotas and staff accounts. The late shift was 2 healthcare assistants below the planned numbers on the day of our visit. These inconsistencies reduced assurance that real-time staffing information was always accurate.

Staffing levels usually enabled patients to have one-to-one time with their named nurse, and staff shortages did not routinely result in the cancellation of escorted leave or ward activities. However, staff told us that staffing pressures, particularly during periods of high sickness or increased incidents, reduced opportunities for therapeutic engagement. People’s experience of staffing was mixed. Some patients told us there were usually enough staff to support planned section 17 leave and ward activities. However, other patients (40%) said that leave or activities were sometimes cancelled or rearranged due to staffing pressures.

Feedback from carers highlighted that staffing pressures and the use of unfamiliar staff sometimes affected people’s experience of care and access to activities. One carer told us that staffing levels were insufficient when they visited the ward and that this affected the support their relative received. One carer said that bank staff “did not know the patients” and raised concerns that reliance on temporary staff reduced continuity of care.

One carer told us that during a planned visit, their relative was due to go out with them as part of a planned cooking activity, but it was cancelled due to staffing issue. They stated that “difficulty of staffing had increased. No one is replaced when staff goes on leave”. This experience contributed to their concern that staffing shortages and reliance on bank staff limited people’s opportunities for meaningful activity and family involvement.

We also reviewed feedback from another carer on another ward, who described mixed experiences of staffing. While they acknowledged occasions where staff were supportive, they also raised concerns about consistency and communication, particularly when staffing was under pressure. Documentation did not consistently evidence how carers’ concerns about staffing and activity cancellations were reviewed or responded to as part of service improvement.

Sickness absence data for August to October 2025 showed variation across wards. Walton and Tallis had consistently low sickness rates. Tavener had the highest sickness rates, rising to 12.3% in September and 12.4% in October, which increased reliance on bank staff and reduced workforce resilience.

Turnover during this period was very low, with only one leaver each from Elgar and Tallis in August 2025 (approximately 1.9%), and no leavers recorded in September or October 2025 across any ward. Supervision compliance was 90% in August, 90% in September, and 86% in October, but dropped sharply in November to 59%. This showed that staff supervision was not consistently maintained over the period reviewed.

Mandatory training compliance between August and November 2025 was consistently high across the service at over 95%. Compliance for Mental Health Act, Mental Capacity Act, Deprivation of Liberty Safeguards, safeguarding and least restrictive practice training was at 100% across all wards This showed that staff had received the required training and understood the principles of safe care. However, reviews of incidents and our observations showed that staff did not always apply this learning consistently in day-to-day practice, particularly when supporting people during physical intervention, responding to safeguarding concerns, and completing observation.

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.