St Andrews Healthcare Northampton

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

This means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question requires improvement. At this inspection the rating remains requires improvement. This means the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care. The service had governance systems in place, but these did not always work effectively in practice. Learning from incidents, complaints and safeguarding concerns was not consistently embedded, and some care records and incident reports lacked clarity and were not fully recorded. Management oversight did not always identify these gaps, which meant opportunities to improve care, dignity and safety were missed.

Systems to share learning were in place. Staff described the use of team meetings, daily huddles and email communications to share information and learning. However, learning was not always sustained or translated into consistent practice across wards. Repeated themes in incidents, observation practice and care recording indicated that lessons were not always embedded, and audit processes did not consistently identify or escalate these issues.

Environmental risks and dignity concerns were not always identified through audits or routine checks. Persistent issues had included compromised privacy and dignity, environmental defects and poor storage system.

Ward managers had the skills, experience and motivation to lead their teams. They were visible on the wards and spoke positively about improving care and supporting staff. Staff described their immediate teams as supportive and committed to providing good care. Staff told us that they were not always confident that concerns they had raised led to clear outcome or result in learning that could have driven improvement.

The service had available systems in place to collect feedback from people and their carers, including community meetings, ward rounds, surveys and direct conversation with staff, However, this feedback did not always lead to shared learning or changes in practice.

The service was in breach of the legal Regulations in relation to good governance (Regulation 17). The provider remained in breach of this regulation.

We have not awarded this service a score for Well-led.

Find out about when we will not publish a key question score and what we look at when we assess Well-led.

The service did not have a shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities.

Staff understood the provider’s vision and values and were able to describe how these were intended to guide care delivery within their teams. Staff told us the organisation promoted person-centred care, safety and respect, and most staff could explain how these values applied to their day-to-day roles.

Although staff understood the overall aim of supporting people with acquired brain injury towards rehabilitation and less restrictive settings, this was not consistently reflected in practice. We identified indicators associated with a closed culture. These included repeated concerns that were not consistently addressed, poor practice that had become accepted as routine, and inconsistent staff engagement with people using the service. Staff described some practices as having “always been done that way”, and senior leaders were not routinely visible on wards, which reduced effective oversight and challenge. Learning from incidents, complaints and safeguarding concerns was not consistently embedded, and governance systems did not always identify, escalate or resolve risks in a timely way. As a result, the provider did not always have assurance that poor practice would be identified, challenged and improved

Senior leaders had communicated the provider’s vision and values to frontline staff through meetings, supervision and written communications. Staff told us these messages were reinforced by ward managers and matrons, and some staff described feeling proud of the work they did.

Staff told us they had opportunities to contribute to discussions about how the service operated, particularly where changes were required following incidents, restrictions or staffing pressures. However, documentation did not consistently evidence how staff or patient feedback influenced strategic decisions or service development. Meetings minutes reviewed emphasised low staff morale and concerns around flexible shift patterns and how this should be managed. While managers described balancing quality and cost pressures, staff were not always able to explain clearly how decisions about resources linked to quality improvement, which reduced assurance that shared ownership of the service direction was fully embedded.

There were safeguarding concerns, including allegations of abuse by staff and failures to speak up during serious incidents involving multiple staff members. These concerns contributed to the service remaining in special measures and subject to restrictions on new admissions. While the provider had begun actions to address cultural issues, including independent reviews and enhanced oversight, these had not yet resulted in sustained improvement. We observed practices that had become normalised over time without clear review or challenge. For example, staff told us that leaving bedroom doors ajar during observations was “what they had always done” and acknowledged they had “probably become blind to it.” This suggests limited evaluation of how routine practices may affect people’s dignity and privacy.

Not all leaders understood the context in which the service delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

Leaders had relevant professional backgrounds and experience, and staff generally described ward managers and matrons as supportive and approachable. Leaders could explain the challenges facing the service and how teams were working to deliver care within a complex acquired brain injury service environment.

Ward managers and senior staff were visible on the wards and staff told us they could approach them with concerns. They were involved in day-to-day operational oversight, including staffing and incident management. Leadership development opportunities were available, including support for career progression.

However, 95% of staff we spoke with told us that the senior leadership team beyond ward manager and quality matron, were not visible on the ward and they only engaged through newsletters and other virtual communication channels. This limited visibility and presence of senior leaders on the wards reduced opportunities for real-time oversight, support and challenge. The absence of consistent senior leadership presence limited assurance that staff felt supported to raise concerns or that learning from incidents and feedback was embedded into daily practice. As a result, leadership systems did not always provide effective assurance that care was safe, person-centred and delivered in line with the provider’s values.

People did not always feel they could speak up and that their voice would be heard.

Staff did not always feel safe to raise concerns. During staff interviews, most staff demonstrated an understanding of the importance of speaking up and were able to describe the processes available to raise concerns. All 23 staff we spoke with told us they would feel confident raising concerns about patient safety or poor practice. However, this understanding was not consistently reflected in practice as some staff also told us that they were not confident that their concerns would be acted upon. As evidenced elsewhere in this report, concerns relating to staff behaviour, dignity and observation practice were not always escalated or addressed promptly.

Information on how to contact the Freedom to Speak Up guardian was displayed in nurses’ offices, and managers encouraged openness during team meetings. However, feedback loops were inconsistent, and some staff lacked confidence that action would follow. Although the service promoted Speak Up routes and safeguarding champions, these measures were not fully effective in creating a culture where all voices were heard without fear of repercussions.

Patients and carers had opportunities to provide feedback through community meetings, direct conversations with staff and complaints processes, as previously referenced. However, feedback reviewed showed mixed experiences. Some carers reported positive engagement, while others described concerns about staff behaviour, dignity and communication. There was limited evidence that feedback was consistently used to drive timely improvement or that people were informed about outcomes.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The service did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.

The service did not have clear responsibilities, roles, systems of accountability or good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Governance arrangements across the hospital involved external oversight, including weekly strategic meetings and monthly meetings with external stakeholders, to support patient safety and ongoing improvement. Ongoing issues across the service included gaps in specialist training, staffing pressures, learning from incidents not always being shared or acted on, weaknesses in reporting and audit processes, and some concerns about staff culture.

The service had governance structures in place, including ward, clinical and divisional meetings, where incidents, safeguarding concerns, complaints, staffing and quality issues were discussed. Wards and services used a range of meetings between August and November 2025 to review risk, and staff described escalation routes and partnership working with internal teams and external agencies. However, but these were not always effective in identifying, escalating and addressing risks or driving improvement.

Audit and risk management systems were in place, but these did not always lead to timely completion or closure of actions. The divisional risk register listed 27 risks, most with actions and named owners, but 74% remained open at the time of review. These included risks linked to observation practice, environmental safety, consistency of care and culture. Audit activity covered areas such as observations, restrictive practice, safeguarding and environmental safety, but records showed that audits did not always result in clear outcomes, measurable improvement or confirmed completion of actions.

Oversight of care delivery and safety was not always effective. Care record reviews identified inaccuracies, including information copied into the wrong records and gaps in documenting capacity assessments and best-interest decision-making. Incident and safeguarding records showed repeated themes involving the same individuals, and action plans did not always demonstrate how risks had reduced over time.

We also identified gaps in assurance with safe practice. Incidents reviewed and observations showed occasions where staff did not follow the provider’s safety intervention policy or used approved safe-hold techniques, including an incident where a staff member on one ward was left to manage a physical hold alone, placing them at increased risk. This occurred despite high reported compliance with mandatory training. This raised concerns about the effectiveness of the provider’s systems for checking competency, supervision and adherence to training in practice.

Environmental and estates oversight was also inconsistent. On one ward, we observed a shower that had been temporarily held together using rubber gloves in a disable communal bathroom. We were told that the service had recently completed an environmental audit. We also identified an empty oxygen cylinder and an expired emollient creams that managers told us they were not aware of. These findings indicated gaps in routine environmental checks, escalation and managerial oversight, and reduced assurance that risks relating to equipment safety were being identified and addressed promptly.

The service had contingency plans for emergencies, including staffing pressures and incidents.

Staff had access to the equipment and information technology needed to perform their roles, and patient records were maintained securely. Information governance systems supported confidentiality. Managers had access to performance, staffing and quality data, but information was not always used effectively to identify trends or prevent recurrence of issues.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.