St Andrew's Healthcare - Birmingham

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

We looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question Requires Improvement. At this assessment the rating has remained the same.

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.

The service used systems and processes to prescribe, administer, record and store medicines. However, we identified some gaps in recording of controlled drugs and where staff had failed to action some medicines fridge temperatures that were outside of the recommended range. We also identified some out of date nutritional supplements that had not been removed from stock. Wards were safe, reasonably clean, equipped, furnished, maintained and generally fit for purpose. However, there were areas that were in need of renovation and deep cleaning. Staff assessed and managed risks to patients and themselves well. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. The service managed patient safety incidents well.

The service was in breach of regulation 12 Safe Care and Treatment because of the ways patients’ medicines were managed.

The provider must follow established guidance when managing patient medicines (Regulation 12(2)(g)) Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulation 12.

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 had a proactive and positive culture of safety, based on openness and

honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

There were no serious patient safety incidents in the last 12 months. There were no adverse events that were specific to this service.

The provider informed all relevant stakeholders, such as commissioners, Care Quality Commission and the local authority safeguarding team of reportable incidents.

All staff knew what incidents to report and how to report them. We reviewed a selection of incident reports and asked staff to give examples of incidents they had reported. Staff reported all incidents that they should report and managers investigated the incidents.

Staff understood the duty of candour. They were open and transparent, and gave patients and families a full explanation, if and when things went wrong. We reviewed incidents where staff honestly recorded what could have been done differently to prevent incidents and complaints that had arisen.

Staff received feedback from investigation of incidents, both internal and external to the service. Staff shared a number of safety bulletins with us that the management team had circulated because they were relevant to the service.

Staff met to discuss the feedback, either as a team or individually with their manager if individual staff development needs were identified as part of the learning from incident framework.

There was evidence that changes had been made as a result of feedback from incidents as well as feedback from stakeholders, staff, members of the public and patients using the service.

Examples of improvements in safety, specific to this service, included an improved admission assessment process for patients with complex physical health needs, such as specialist wound care or bariatric equipment tailored to their needs.

Staff were debriefed and received support after a serious incident. Most staff told us they found the debriefs and post-incident support very helpful. One member of staff said they could have been offered more individualised support following an assault by a patient.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The service’s referral and admission processes ensured that all essential information about the patient was received to determine if the patient’s needs could safely be met. Lessons learned from a complex admission had led to staff updating the admission process.

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. However, while outside of the hospital’s control, some staff and patients told us people’s discharge could be delayed while they waited for local authority social care teams to assess their needs under the Care Act 2014 along with waits for suitable accommodation for them to move on to.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Staff were trained in safeguarding, knew how to make a safeguarding alert, and did that when appropriate. Staff were up to date with safeguarding training, with 95% of them having completed it.

Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act 2010.

Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies.

Staff followed safe procedures for children visiting the service.

Restraint was only used as a last resort and we saw good evidence of staff using de-escalation techniques. Three wards had no episodes of restraint between January – June 2025. The hospital as a whole recorded only 48 episodes during the same period, with Hawkesley ward having the highest number of 26. Staff and patients told us that restraint was rarely used across the hospital. We saw that when used, restraint was used for the shortest amount of time to keep people safe.

Patients told us there were restrictions on some wards, such as when they could use the garden or laundry room. However, they told us they understood why there were some restrictions because staff were open about it and explained why they were needed. Some patients told us they all had to live with some restrictions while there were problems with antisocial behaviour in the community, such as people throwing illegal drugs into the hospital grounds. The provider had plans to further increase security of the hospital grounds and had installed security staff at the main entrance until that work could be completed.

Restrictive practice was closely monitored and the provider had clear governance processes for reviewing this. There was a multidisciplinary staff meeting each month which monitored restrictive practice with the aim of making sure any restrictive practice was reviewed to see if it could be reduced or ended. Some blanket restrictions were in place but these were proportionate to the level of risk present. Staff made sure patients understood why certain restrictions were put in place and what needed to change for restrictions to be reduced.

Mental Capacity Act

95% of staff were up to date with their training in the Mental Capacity Act 2005.

Staff had a good understanding of the Mental Capacity Act, in particular the five statutory principles and gave examples of how they applied the Act when supporting patients to make decisions.

There were no of deprivation of liberty safeguards applications made to protect patients without capacity to make decisions about their own care because patients using the service were detained under the Mental Health Act.

The provider had a policy on the Mental Capacity Act, including deprivation of liberty safeguards. Staff were aware of the policy and had access to it.

Staff knew where to get advice from within the provider regarding the Mental Capacity Act, including deprivation of liberty safeguards.

Staff took all practical steps to enable patients to make their own decisions.

For patients who might have impaired mental capacity, staff assessed and recorded capacity to consent appropriately. They did this on a decision-specific basis with regard to significant decisions.

When patients lacked capacity, staff made decisions in their best interests, recognising the importance of the person’s wishes, feelings, culture and history.

The service had arrangements to monitor adherence to the Mental Capacity Act.

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. However, staff used restraint and seclusion only after attempts at de-escalation had failed participated in the provider’s restrictive interventions reduction programme.

Our assessment team reviewed 35 patient care records, including their risk assessments / risk management plans. We found patients’ voices were included and staff made sure they recorded when patients disagreed with the professional assessments.

There were 48 incidences of restraint across the service between January – June 2025. Hawkesley ward had the highest number at 26, of which 4 were in the prone position. Rapid tranquilisation had been administered 8 times across the hospital in the last 6 months, seclusion had been used 26 times and long-term segregation 4 times.

We reviewed 6 incidents and 3 seclusion documentation. We found one seclusion review did not meet the composition to be classed as a full multidisciplinary review. We raised this straight away with the provider.

Staff involved patients in care planning and risk assessment. Patients’ care plans showed when their views differed from staff and showed what they hoped to achieve during their patient journey. Records showed that patients were invited and encouraged to attend the meetings staff arranged to review their care and treatment, such as multidisciplinary team reviews. Staff did not always record when they offered patients a copy of their care plan or record when they offered patients a copy but the offer was declined. However, patients told us they understood what their care plan was for.

Patients gave mixed feedback about involvement in their risk assessments and the assessment of their needs. Most said they were involved but other patients said they had limited involvement. Some patients told us they did not want to be involved. Some patients told us they were involved as much as they wanted to be with their risk assessments and care plans. Some patients told us they were not as involved as they would like to be.

The service complied with the Accessible Information Standard (AIS). Staff communicated with patients so that they understood their care and treatment, including finding effective ways to communicate with patients with communication difficulties. This included by supporting patients who wanted to learn to read and providing information in different languages or different formats.

Staff encouraged patients to give feedback on the service they received. We observed 4 community meetings and saw that staff were skilled at encouraging patients to share their thoughts and feelings about numerous aspects of their care. Managers told us about some of the programmes they were developing (and some they had developed in the past) that were designed jointly with patients, to make sure they understood how patients experienced their admission at the hospital and where improvements could be made.

Staff explained that they had limited experience of supporting patients with end-of-life care planning, but were confident they could hold difficult conversations to support patients when they needed or wanted to have them. This included enabling patients to make advance decisions (to refuse treatment, sometimes called a living will) when appropriate.

Staff made sure patients could access independent advocacy services. Notice boards showed patients how to contact the advocacy service. Patients told us they knew how to speak with an advocate and if they needed help from staff to do this, staff were supportive. However, patients also told us that there had been a recent change in the contract that commissioned independent mental health advocacy. This meant that the advocates no longer made regular and unplanned visit to the wards. Patients told us they missed being able to speak with an advocate quickly and they found the new process of booking appointments ahead of time was unhelpful. We fed this back to hospital managers who agreed to gather more patient feedback and review the new process.

The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Staff did regular risk assessments of the care environment. If they identified areas of risk they reported it to managers.

Ward layout did not always allow staff to observe all parts of ward. We noted a “blind sport” in the same place on all the wards so raised this with managers. We were informed a recent site visit carried out by the commissioners had also raised this concern. Ward staff assured us these areas had not been the cause of any incidents and managers assured us they were considering installing closed circuit television monitoring to help manage any risk.

There were some potential ligature anchor points – but staff had identified them and mitigated the risks adequately. Staff told us they mitigated risk by being present in the relevant areas, by using individual patient risk assessment and by carrying out patients’ individually prescribed therapeutic observations. Staff were aware of where ligature cutters were kept so they could find them in an emergency. There had been no reported safety incidents in relation to these areas.

The ward complied with guidance on eliminating mixed-sex accommodation. All wards had ensuite bathroom facilities.

Staff had easy access to alarms and patients had easy access to nurse call systems (in wards where this was necessary). Regular checks were in place to make sure these worked effectively.

Seclusion rooms allowed clear observation and two-way communication. They had toilet facilities and a clock. We reported two clocks showing either incorrect time or day, but staff resolved the issues straight away and noted that none of the patients on those wards had needed to use the seclusion room for a number of years. An improvement programme had recently provided upgrades and renovation work to all the seclusion rooms, even on the wards where patients were never subject to seclusion.

Closed circuit television monitors had been installed in the courtyard and seclusion areas. The provider was considering options to extend this to other areas of the hospital based upon risk assessments of the environment.

Arrangements to monitor the safety and upkeep of the premises had improved. Staff reported maintenance and repair issues through a maintenance logging system. Despite a reduction in maintenance staff, repairs in recent months were handled more quickly. However, repairs could be delayed if specialist parts were required. Staff and patients were complimentary about the maintenance worker, particularly how responsive they were to patient requests.

The provider had received funding to upgrade the environment. We saw evidence of improvement work during our visit. Staff told us the programme was taking some time to complete but they were pleased the facilities were improving for patients, such as refurbished bathrooms and kitchens.

Patients told us they were satisfied with the environment at the hospital and getting maintenance issues resolved had improved in recent months but some things could still take time, such as getting the temperature right for everyone. Most patients were satisfied with the temperature on the wards but some found it too hot and others found it too cold.

Each ward had access to a clinic room and resuscitation equipment. The provider carried out emergency response exercises, so staff could confidently respond in a timely manner in the event of an emergency.

The technology staff used did not consistently support them to perform their duties. There were no reported issues during our visit, but most staff told us the internet signal could “drop” in some areas of the hospital which would cause a few minutes delay in them updating the electronic patient records because they used handheld “tablets” to document patients’ therapeutic observations. When this happened, they had to move to another part of the ward to find a signal or use an office fixed terminal computer. This meant they were not always able to record their observations in “real time” as they needed to walk along the corridor and into the office to complete their recording.

Most staff told us the electronic medicines system could be slow, especially for patients who were prescribed lots of different medicines, if staff needed to check drug interactions and if lots of staff were using the system at the same time. If the internet connection was interrupted, the system was even slower to use. This meant that it took staff longer than necessary to manage and record patients’ medicines. Most staff with responsibility for dispensing medicines told us the system was good except for these regular delays. There had been no safety incidents in relation to this issue. The provider gave assurances that the safety and effectiveness of the information technology system was always under review to look for ways to improve it.

The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Staff did regular risk assessments of the care environment. If they identified areas of risk they reported it to managers.

Ward layout did not always allow staff to observe all parts of ward. We noted a “blind sport” in the same place on all the wards so raised this with managers. We were informed a recent site visit carried out by the commissioners had also raised this concern. Ward staff assured us these areas had not been the cause of any incidents and managers assured us they were considering installing closed circuit television monitoring to help manage any risk.

There were some potential ligature anchor points – but staff had identified them and mitigated the risks adequately. Staff told us they mitigated risk by being present in the relevant areas, by using individual patient risk assessment and by carrying out patients’ individually prescribed therapeutic observations. Staff were aware of where ligature cutters were kept so they could find them in an emergency. There had been no reported safety incidents in relation to these areas.

The ward complied with guidance on eliminating mixed-sex accommodation. All wards had ensuite bathroom facilities.

Staff had easy access to alarms and patients had easy access to nurse call systems (in wards where this was necessary). Regular checks were in place to make sure these worked effectively.

Seclusion rooms allowed clear observation and two-way communication. They had toilet facilities and a clock. We reported two clocks showing either incorrect time or day, but staff resolved the issues straight away and noted that none of the patients on those wards had needed to use the seclusion room for a number of years. An improvement programme had recently provided upgrades and renovation work to all the seclusion rooms, even on the wards where patients were never subject to seclusion.

Closed circuit television monitors had been installed in the courtyard and seclusion areas. The provider was considering options to extend this to other areas of the hospital based upon risk assessments of the environment.

Arrangements to monitor the safety and upkeep of the premises had improved. Staff reported maintenance and repair issues through a maintenance logging system. Despite a reduction in maintenance staff, repairs in recent months were handled more quickly. However, repairs could be delayed if specialist parts were required. Staff and patients were complimentary about the maintenance worker, particularly how responsive they were to patient requests.

The provider had received funding to upgrade the environment. We saw evidence of improvement work during our visit. Staff told us the programme was taking some time to complete but they were pleased the facilities were improving for patients, such as refurbished bathrooms and kitchens.

Patients told us they were satisfied with the environment at the hospital and getting maintenance issues resolved had improved in recent months but some things could still take time, such as getting the temperature right for everyone. Most patients were satisfied with the temperature on the wards but some found it too hot and others found it too cold.

Each ward had access to a clinic room and resuscitation equipment. The provider carried out emergency response exercises, so staff could confidently respond in a timely manner in the event of an emergency.

The technology staff used did not consistently support them to perform their duties. There were no reported issues during our visit, but most staff told us the internet signal could “drop” in some areas of the hospital which would cause a few minutes delay in them updating the electronic patient records because they used handheld “tablets” to document patients’ therapeutic observations. When this happened, they had to move to another part of the ward to find a signal or use an office fixed terminal computer. This meant they were not always able to record their observations in “real time” as they needed to walk along the corridor and into the office to complete their recording.

Most staff told us the electronic medicines system could be slow, especially for patients who were prescribed lots of different medicines, if staff needed to check drug interactions and if lots of staff were using the system at the same time. If the internet connection was interrupted, the system was even slower to use. This meant that it took staff longer than necessary to manage and record patients’ medicines. Most staff with responsibility for dispensing medicines told us the system was good except for these regular delays. There had been no safety incidents in relation to this issue. The provider gave assurances that the safety and effectiveness of the information technology system was always under review to look for ways to improve it.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. However, some areas were in need of upgrading, renovation and deep cleaning.

Staff maintained equipment well and kept it clean.

All ward areas were generally clean, had mostly good furnishings and were well-maintained. Some furniture showed wear and some areas of the building looked tired and in need of redecoration. Patients and staff explained the improvement work that the hospital was carrying out. All wards kept clear maintenance request records. Managers audited the length of time repairs took to complete.

Cleaning records were up to date and demonstrated that the ward areas were cleaned regularly. Regular ward cleanliness audits were carried out by managers. Some areas for improvement had been identified, so an “improvement plan” was recently put in place to make sure housekeeping staff could carry out more “deep cleaning”. Ward staff would assist, by providing extra support for patients who routinely refused to allow housekeeping to come into their room or for patients who showed hoarding behaviours.

Staff told us they were given training to understand and carry out good infection prevention and control actions. Training records showed 96% of staff were up to date with their training.

Managers carried out random practice audits, for example testing staff to check they were following best practice with hand washing, identifying and feeding back to staff any areas they needed to improve. We observed staff adhered to infection control principles, including handwashing and noted they ensured professional visitors to the hospital did the same. There was some inconsistencies with the use of “I am clean” stickers but there had been no patient safety issues in relation to infection prevention and control measures at the hospital.

Staff could easily access the policies and procedures relating to infection prevention and control. The policies we looked at were all up to date and linked to national guidance.

The service did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning.

The concerns demonstrate a breach of Regulation 12 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The service had policies and procedures to support staff to prescribe and administer medicines safely.

Staff reviewed the effects of medication on patients’ physical health regularly and in line with NICE guidance, especially when the patient was prescribed a high dose of antipsychotic medication.

Clinic rooms were clean and well organised. All medicine drawers and trolleys were locked. Medicines and clinical waste were disposed of appropriately with access to medicine waste bins.

We were told staffing levels had improved recently to support with safe medicines management.

Where patients were detained under the Mental Health Act, paper versions of consent to treatment documents, that provide the legal authorisation for the administration of certain medicines, were kept in folders. On 3 wards we saw that the documents in the folders were not the most up-to-date versions. Staff were unable to tell us the purpose of the folder as they told us they checked the forms on the electronic patient record. However, when asked to show the latest consent to treatment documents, 2 nurses were unable to locate them on the computer. A patient had moved from a T3 to T2, however both forms were still in the folder on the ward. These findings presented a risk that staff may not have access to the correct legal authorisation for the administration of certain medicines. There was no assurance that these discrepancies had been identified through clinical oversight or governance processes.

Fridge temperatures were recorded. However, on Hawkesley ward we saw examples where the maximum temperature went over 8 degrees on 7 consecutive days and no action was taken with stock in the fridge. On, Hazelwell ward and we saw the minimum had gone below 2 degrees for most of the month and no action was evident. This fridge stored insulin. Weekly audits had been completed but had failed to identify if these discrepancies had been managed appropriately. There was a lack of oversight in ensuring temperature-sensitive medicines were stored safely. We raised this with managers during the assessment visit.

Emergency medicines and equipment were available on the wards. However, not all nursing staff were aware of the minimum quantities of each medicine that should be stocked. While staff stated that weekly checks of stock levels and expiry dates were being carried out, evidence to support this was only available on one ward. We could not be assured that emergency medicines were being monitored and maintained in a consistent way across all wards.

During the inspection we observed that on 2 occasions across Edgbaston and Hawkesley wards, entries in the Controlled Drugs (CD) register did not reflect a second nurse’s signature, to confirm the CD quantity dispensed had been double-checked, at the time of administration. This is not in line with expected practice, which requires two nurses to sign the CD register when a medicine is removed from the CD cupboard for administration to a patient.

Additionally, a discrepancy was noted in the recorded quantity of a Schedule 3 CD. The register entry included signatures from two nurses, despite the quantity being incorrect. This raised concerns regarding the accuracy of CD documentation and the robustness of the checking process. We raised this straight away with managers at the hospital.

Patients and staff told us that Rapid Tranquilisation (RT) was almost never used on the wards. We observed RT to be rarely used in the wards and only as a last resort which displayed effective use of verbal de-escalation. When asked, nurses were aware of the post-monitoring required after RT. However, Flumazenil, a reversal agent for RT usually used in an emergency, was not stocked in the hospital yet not all staff were aware of this. Most nurses when questioned about this medicine did not know about its intended use. This posed a potential risk to patient safety in the event of an overdose to benzodiazepines, as staff did not have the knowledge of a clear process to follow in the absence of the hospital stocking flumazenil.

Staff could not tell us where the list of nurses signatures were kept on wards to help verify which nurse had signed clinical documentation. We were later told that pharmacy kept an electronic version and a paper copy was available in a folder on the wards. The lack of immediate access and awareness of the location of nurse signatures raised concerns around oversight by staff on wards.