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 last assessment we rated this key question Inadequate. At this assessment the rating has changed to 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 to learn from incidents and embed lessons learnt were not consistently applied. Risk assessments were in place, but care plans lacked sufficient detail. Daily progress notes were often task-oriented, which could compromise continuity of care. Staffing had continued to remain a challenge, with continued reliance on bank staff. There had been some occasional reported delays in meeting personal care needs. Unexplained injuries continued to occur, and some care plans did not fully support safe, person-centred care.

However, there had been some improvements since the last inspection. We found better documentation of injuries and restrictive practices being individually risk assessed rather than applied as blanket restrictions. Staff understood safeguarding processes and compliance with mandatory training was high.

The provider was previously in breach of the legal Regulations in relation to safe care and treatment (Regulation 12), safeguarding (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 always have a proactive and positive culture of safety based on openness and honesty. They did not always listen to concerns about safety. The service had systems to learn from incidents and share lessons learnt, but these were not always applied consistently.

Staff discussed risks and learning in team and governance meetings. In team meetings, there was a standing agenda item for learning from incidents and investigations. Staff who attended these meetings had been directed to a lesson learnt file located in the ward office. In the team meeting minutes we reviewed, there were no specific new incidents or lessons discussed during the meeting, which was a missed opportunity.

Learning alerts had been created by senior staff. Ward managers cascaded this information through staff meetings and made the alerts available to all staff on the wards. We saw 2 different formats of learning alerts. One format was dated, identified what was found, learning from this and actions taken / to be taken by staff. We saw 2 examples of alerts which highlighted airlock areas needing to remain clutter free and safe for patient transfers, and another which highlighted staff had been using blankets and towels provided for patients.

The second learning alert format highlighted what went wrong and how staff could fix this. These documents did not have a date, but the provider informed us these were from August, September and October. Examples had included the safe disposal of ampoules (a small container holding a single dose of medicine) and protocols for patients returning from acute general hospitals, to ensure staff were fully up to date with care and treatment received and any follow up actions required.

While lessons from incidents had been shared, some staff were unaware of recent incidents, indicating that learning was not fully embedded. Six out of 9 staff we spoke with were unable to give us an example of a recent incident and learning from this. Reflective practice was offered to all staff on a weekly basis. Staff on Redwood ward had voiced challenges with attending these due to staffing and workload during a recent team meeting.

The wards had found it difficult to capture the voices of patients during community meetings. On Redwood ward, staff spoke individually with each patient, asking a set of questions, in an attempt to gather as much feedback as possible. Not as much feedback from patients had been recorded from documentation seen relating to Cherry ward.

The service did not always manage or monitor people’s safety. They did not always make sure there was continuity of care. The service worked well with healthcare partners to establish and maintain safe systems of care.

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.

Staff explained that any new referrals would be received into the service and assessed by the multidisciplinary team (MDT). If the service was able to meet the needs of the patient, relevant information regarding the patient including care plans, positive behavioural support plans and risk documents, would be shared with the ward team prior to the patient being admitted.

The service had continued to use bank and agency staff to cover shifts, so there was not always good continuity of care, despite managers trying to book staff who were familiar with the ward. Staff continued to voice difficulty in being able to spend time positively engaging with patients as the majority of patients required support from at least 2 staff to assist with personal care, hydration and diet, leaving little time for other activities.

Senior staff undertook regular audits of enhanced observations. We saw one had been completed in August 2025 on Cherry ward which reported no immediate concerns.

Not all patient general observations had been completed in a timely way. On one occasion, these observations had been delayed by 30 minutes due to no staff being available. An incident form had been completed to reflect this. On Redwood ward in August, 80% of observations had been reported to have been completed on time. This demonstrated some difficulties staff had adhering to hospital policy to ensure patients were kept safe, with necessary interventions being given in a timely way.

Staff had worked with external agencies and commissioners to identify potential ongoing placements for patients in anticipation of the service closure. We saw that 1 patient was on a trial period of leave in a new service. The staff had been communicating with the new placement regularly to check upon progress and offer any advice needed.

The service did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

The service had processes in place to identify and respond to safeguarding concerns and staff knew how to escalate concerns. Staff compliance with safeguarding children and adults was over 90%. Between 01 August and 28 October 2025, staff recorded 175 safeguarding incidents. Of these, 151 were minor and did not require reporting to the Local Authority. Staff had made 24 referrals to the Local Authority; 5 were closed immediately, while 19 needed further investigation by either the provider or the Local Authority. This equated to 79% of referrals requiring additional action.

The referrals included 9 cases involving physical aggression or violence, 5 allegations of abuse, and 4 incidents related to injuries or physical health. Other concerns had been raised about medication management, security, and incidents of deliberate self-harm. While most of these incidents resulted in little or no harm, 9 had been classified as causing moderate harm.

Across both wards between August and November 2025, staff had reported 16 unexplained injuries observed on patients. Most of these were scratches/cuts, redness and or bruising. Staff had competed an incident form for each incident and had also completed a body map. However, it was concerning staff were unaware of how these injuries had been sustained, as most of these patients required support in most aspects of day-to-day activities, and those considered to be at risk of injury, for example, due to falls, were on enhanced observations.

There had been some improvements since the last inspection. Documentation following incidents demonstrated what actions staff had taken. Managers had placed emphasis upon accurate recording of any observed injuries.

Staff used restraint as a last resort. Low level holds were reported to be used at times when supporting patients with personal care. Restrictive practices, such as having free access to outside areas, and the use of metal cutlery was logged within the wards restrictive practice log. Staff individually risk assessed patients, as opposed to having blanket restrictions applied to all, an improvement from previous assessments.

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.

The service had systems to assess and manage individual risks, but these were not always comprehensive or consistently applied. We reviewed 8 care records. All had up-to-date risk assessments that had been regularly reviewed by staff. Three care plans we reviewed included the need for enhanced support. Two of these clearly stated how close staff should remain when supporting the patient. One care plan lacked this detail despite them being mobile and at risk of falls.

Day-to-day records were often task-oriented and lacked detail. For example, we saw that staff had changed a catheter for one patient but had not recorded this in the daily progress notes. While this had been reflected in the corresponding care plan, we were concerned this information could be overlooked and not be handed over to oncoming staff. We also saw that a recent discharge meeting had not been reflected in the patients’ daily notes. There was a risk that staff would not be fully informed of all support given to patients. One staff member told us completing daily notes could be rushed when short staffed, which resulted in basic recording only.

The total number of reported incidents between August and November 2025 across Cherry and Redwood wards totalled 208. The top 3 themes of incidents reported across Cherry and Redwood wards fell under physical violence and aggression, falls and accident and injuries.

The risk of choking continued to be a risk across both wards. We noted there had been an incident in September where a patient had been given inappropriate food. Staff reported “rushed care” due to staffing shortages, which had contributed to the error. There was no reported harm to the patient.

Minimal restraints had been recorded across both wards, despite many care plans indicating assistance from 2 or more staff was required to support with personal care. We were concerned that low level restraints during personal care had not been consistently recorded by staff.

Care plans were not always clear about the level of support the patients needed, what they were able to do independently, or with support, and what they disliked, to minimise the risk of distress. When we discussed this with staff, it was acknowledged that some care plans lacked detail.

There had been some improvements since the last inspection. Staff had improved recording of unexplained injuries and had completed body maps following incidents to highlight if any observed injuries. Staff had maintained diet and fluid charts for patients who were at risk of dehydration or malnutrition.

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 always 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 always work together well to provide safe care that met people’s individual needs.

The service had systems to ensure safe staffing, although there was a high reliance upon bank staff to cover shifts. Between 01 August and 30 September, 2025, on Cherry ward, bank staff were used in 47 days out of 61. On Redwood ward during the same time, bank staff had been used to cover 58 out of 61 days. The use of agency staff had reduced significantly across both wards. Staff sickness was 4.3% on Cherry (below national average) and 8.1% on Redwood, above the national average. This sickness accounted for some staffing gaps across the wards.

Occupancy had reduced over time due to the planned closure of the older people’s wards. Managers had adjusted staffing numbers to meet the needs of remaining patients. On Redwood ward, there were 5 patients at the time of our visit. Staffing consisted of 2 registered nurses and 3 healthcare assistants. Two of the 5 patients were receiving 1:1 enhanced observation. Cherry ward also had 5 patients with 2 registered nurses and 3 healthcare assistants. One of the 5 patients were receiving 1:1 enhanced observation.

Feedback from staff was mixed. Most staff we spoke with said there was enough staff most of the time to meet patient’s needs. One staff member said that if a patient needed assistance from 3 staff to assist with personal care, staffing would be temporarily reduced on the wards, which at times had made meeting all needs in a timely way difficult. Governance meeting minutes recorded some difficulties with staff completing personal care in a timely way. We saw an incident form completed in September after a patient on a ward was found soiled for a significant time before being assisted. We also saw an incident form completed in September as patient observations had been delayed by 30 minutes due to staff shortages. These examples show how staffing shortfalls had affected dignity and timely care on occasions.

There had been some improvements with activities since our last inspection. Staff reported that planned activities were no longer routinely cancelled, and patient’s observations had been completed on time in October. MDT staff members supported patients on the wards. We observed occupational therapy staff spending time with patients throughout our visit.

Staff had received and were up to date with mandatory training, with compliance being over 90%. Two areas of risk requiring further staff training from previous inspections was around dysphagia and specialist dementia and Huntington’s’ disease training. Training had not been completed due to upcoming ward closures.

There was a gap in staff knowledge regarding balloon Percutaneous Endoscopic Gastronomy (PEG) care (feeding tube) highlighted which had been escalated divisionally. The explanation for this training gap was unclear in documentation seen.

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.