St Andrew's Healthcare - Essex

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• 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 as requires improvement. At this assessment the rating has improved to good. This meant people were safe and protected from avoidable harm.

The service worked with people to understand what being safe means to them as well as with partners on the best way to achieve this. People were safe and protected from bullying. Patients were supported to make choices that balanced risks of harm with positive choices about their lives. Leaders ensured there were enough skilled people to deliver safe care that promotes choice, control and individual wellbeing. Compliance rates for mandatory training and supervision were good.

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.

We scored the service as 3. The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

All staff knew what incidents to report and how to report them. Staff demonstrated good understanding of learning from incidents and were able to give us relevant examples of lessons learnt following incidents.

Staff reported serious incidents clearly and in line with provider policy. Staff recorded incidents on an electronic incident reporting system. All incidents were reviewed by managers in morning meetings and in clinical governance meetings.

Staff understood the duty of candour. They were open and transparent and gave patients and families a full explanation if things went wrong.

Managers debriefed and supported staff after any serious incident, which included all members of the multi-disciplinary team.

Managers investigated incidents thoroughly using the ‘Patient Safety Incidence Response Framework (PSIRF)’. Following a serious incident, managers completed an ‘After Action Review (AAR)’ which identified system issues which led to the incident and actions taken to prevent a reoccurrence. We saw an example of an AAR completed following an incident where a patient was found to have contraband in their bedroom. Managers took clear steps to reduce the risk of this happening again, such as additional training for staff and creating a dedicated mailing list for the ward.

Staff feedback and clinical governance meetings demonstrated that learning from incidents was regularly shared and that processes had been embedded. For example, staff and managers described being involved in learning and participating in staff meetings, supervision, de-briefs, reflective practice meetings and team meetings. Staff also spoke about receiving regular incident information in the form of e-mails and regular incident briefings.

We scored the service as 3. The provider 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.

Staff made sure they shared clear information about patients and any changes in their care, including during handover meetings. Staff held morning meetings attended by managers and members of the multi-disciplinary team and nursing staff held handover meetings at the end of each shift.

Ward teams had effective working relationships with external teams and organisations. Our review of records from Multi-Disciplinary Team (MDT) meetings indicated involvement of family members, key stakeholders, and care teams in discussing patient progress, future care planning transitions and discharges.

We received feedback regarding hospital systems, pathways, patient flow, safety and quality from NHS commissioners and other external stakeholders. Stakeholders told us that communication with hospital managers and staff was generally effective, and they were made welcome at the service. However, 1 stakeholder told us that communication could be improved, as there were sometimes delays and inconsistencies with patients receiving the support they require.

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. We saw that discharge planning was evident from the point of admission in the all the care records we looked at. We saw detailed and personalised discharge planning, including consideration of moving the patient closer to home and ensuring they had access to specialists to ensure safe reintegration to society.

We scored the service as 3. The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff 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 provider shared concerns quickly and appropriately.

The service had an adult at risk safeguarding policy, last updated in February 2026, and clear processes in place for staff to follow. Staff received training on how to recognise and report abuse, appropriate for their role. All staff completed mandatory level 3 safeguarding training, and at the time of inspection, compliance was at 100%.

The hospital had a safeguarding lead and information about how to contact them was displayed around the hospital. Social workers based within the hospital took the lead on making referrals to the local authority. Staff held multi-agency safeguarding meetings with the organisational safeguarding team at the local authority to review and discuss individual safeguarding referrals and agree actions.

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

Staff followed clear procedures to keep children visiting the ward safe. There was a family room adjoined to the main reception building where visits could be held so young children did not have to go into the main hospital. At the time of inspection, 100% of staff were compliant with safeguarding children and young people training.

The service had a least restrictive practice policy which was updated in April 2026 and stated the service commitment to reducing restrictive practices and applying these principles in all aspects of service design, delivery and development. The policy described the arrangements for authorising, monitoring and reviewing restrictive practices, including ‘blanket restrictions’ (restrictions that applied to all patients on the ward), and included guidance to involve patients where possible. The service appointed least restrictive practice ambassadors to help teams reduce unnecessary patient restrictions and strengthen safer, more consistent care.

We scored the service as 3. The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We scored the service as 3. The provider worked with people to understand and manage risks by thinking holistically. Staff provided 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. Risks were reviewed by the multidisciplinary team each day. We looked at 4 patient care records and could see that risk assessments had been completed on admission, were up to date and had been reviewed and updated after incidents.

Staff knew about patient’s individualised risks and acted to prevent or reduce them. Potential risks for patients included self-harm, suicidal ideation, self-neglect, non-compliance with treatment, absconding or risks to other people. Some patients were vulnerable and were at risk of exploitation from others.

Staff involved patients in care planning and risk assessment. We saw evidence that patients had been involved in their care planning, with plans shaped around what mattered to them alongside mental health needs and risk management. However, staff did not always record in care plans whether they had offered patients a copy of their care plan. Some patients had seen copies of their care plans, and 1 we looked at was recorded as not being willing to engage with their care plan.

In the 3 months prior to the inspection the provider reported 2 incidents involving restraint and 3 incidents involving the use of rapid tranquilisation on Danbury Ward. There was 1 incidence of prone restraint which was employed as a last resort to ensure the safety of both the patient and staff. One patient we spoke with told us that a full debrief was held with them after they were restrained.

All staff involved in restraint were trained in CPI (crisis prevention institute) safety intervention advanced and emergency training. There were 3 incidents of seclusion, and 1 patient was supported in long term segregation. Staff made every attempt 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 completed training in the use of restrictive interventions – 95% of staff had completed training in relational security at the time of inspection and 100% of staff had undertaken the 5 day safety intervention training. Staff we spoke with were able to tell us about the various de-escalation techniques they would use such as verbal de-escalation and utilising a low stimulus environment or distraction. We saw an example in a care plan where there was a clear de-escalation approach documented following an episode of distress.

All patients had access to an independent mental health advocate (IMHA) during their stay at the hospital. Information about how to access the advocate was displayed around the wards and given to patients on admission. We spoke with the IMHA for the service who told us ward managers were accommodating, approachable, and readily available to support and respond to any concerns raised on behalf of patients. However, there could be delays or inconsistencies in referrals in situations requiring more immediate or one-off support, such as upcoming CPA meetings or Managers’ Hearings.

When incidents occurred, staff responded promptly, documented incidents accurately, and updated care plans and risk assessments. All the staff knew what incidents to report and how to report them. Staff demonstrated a clear understanding of what constituted a sexual safety incident and how this would be managed.

We scored the service as 3. The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

During the inspection we undertook a tour of the whole ward. We observed that the ward was clean, well-maintained, well-furnished and fit for purpose.

Staff could not easily observe patients in all parts of the wards and outside space. However, the service had fitted convex mirrors to monitor communal areas and used relational security and enhanced observations to support patients with additional risks. The service did not have closed circuit TV (CCTV) on any of the wards. Staff told us this could impact on the time it took to investigate incidents as they were unable to review CCTV footage to confirm what happened or highlight poor or good practice. Managers were undertaking a survey at the time of inspection with a view to installing CCTV at the service dependent on the cost.

The ward complied with guidance and there was no mixed sex accommodation – the ward was for male patients only.

Staff knew about any potential ligature anchor points and mitigated the risks to keep patients safe. Ligature cutters were stored on the ward in a locked yellow box that required a key to access. This could potentially delay access in an emergency. The service relied on a limited range of ligature cutters (cutter & scissors). This potentially increased risk as it is best practice is for wards to have ligature packs containing a range of items such as a ResQhook, fish knife (or similar cutter), scissors, and wire cutters. However, all staff held a key to access the ligature cutters, and there had not been any incidents at the hospital where harm had been caused by a delay in accessing ligature cutters or by not having non-standard ligature cutters.

Staff had easy access to alarms and patients had easy access to nurse call systems.

Clinic rooms were clean and fully equipped, with accessible resuscitation equipment and emergency drugs that staff checked regularly. However, we did not see any cleaning records at the time of inspection.

The seclusion room utilised for Danbury ward allowed for clear observation, had a toilet and washing facilities, a clock, a two-way intercom system and was well ventilated.

Each patient had their own bedroom, which they could personalise. All bedrooms had ensuite facilities.

Patients had a secure place to store personal possessions. Lockers were available for patients to store valuable items.

Staff had access to a full range of rooms and equipment to support treatment and care. The ward had a clinic room, rooms that could be used for 1-1 meetings, group work, therapy and activities. In addition, patients had access to a pleasant courtyard garden, sports hall, gym, classroom, café and an ADL (activities of daily living) kitchen on the hospital site.

The service displayed the names and photos of all staff on each ward, so that staff and visitors were aware of the staff working on the wards.

We scored the service as 3. The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

We looked at the staffing figures for the service. At the time of the inspection the ward had a whole-time equivalent staffing establishment of 7 registered nurses and 16 healthcare assistants. The vacancy rate was low. Within the multi-disciplinary team there were vacancies for 1 consultant psychiatrist, 1 assistant psychologist and 1 occupational therapist. There was 1 fixed term lead social worker covering maternity leave.

The service had low use of bank staff to cover annual leave and sickness absence. Where additional cover was needed, the service used bank staff who knew the patients well, as they already worked within the service. The service did not use agency staff.

During the inspection we could see the wards were fully staffed, and staff told us that there were enough staff on the wards. Patients said there were always staff visible on the wards.

There was adequate medical cover day and night and a doctor could attend the wards quickly in an emergency.

Staff had completed and kept up to date with their mandatory training. Overall, staff compliance with mandatory training was 95%. There was no mandatory training with a compliance rate of less than 85%, except for alarm training which was not due for staff until the end of May 2026. The mandatory training programme was comprehensive and met the needs of patients and staff.

Managers monitored mandatory training and alerted staff when they needed to update their training. Managers received a regular report showing compliance with mandatory training. This report included details of training that was soon to expire.

Managers supported permanent staff to develop through yearly, constructive appraisals of their work. At the time of inspection 98% of staff were up to date with their appraisal.

Managers supported staff through regular, constructive clinical supervision of their work. Clinical and managerial supervision compliance was at 100% at the time of inspection.

Managers identified the learning needs of staff and provided them with opportunities to develop their skills and knowledge. For example, staff who began working at the service as healthcare assistants were supported to undertake registered mental health nurse training.

Managers dealt with poor staff performance promptly and effectively.

Managers gave each new member of staff a full induction to the service before they started work.

We scored the service as 3. The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Staff maintained equipment well and kept it clean.

All ward areas and clinic areas were clean and well maintained. We could not see cleaning records at the time of inspection as they were unavailable, however we did receive these after the inspection.

Staff conducted infection prevention audits. We saw evidence of completed audits of patient equipment and mattresses.

Staff followed infection control policy, including handwashing. Masks and hand gel were available at reception and at the ward entrances and staff followed personal protective equipment guidelines. However, we did see that some refrigerated food items had not been labelled once opened and saw one food item in a fridge that was out of date. We raised this with the provider who gave assurances that this had been rectified.

Posters were displayed at the hospital reminding staff and visitors to wash their hands. Compliance for mandatory training in infection control was 100% at the time of inspection.

We scored the service as 3. The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Staff followed systems and processes to prescribe and administer medicines safely.

Staff reviewed each patient’s medicines regularly and provided advice to patients and family members about their medicines. Patients’ medicines were reviewed as part of an overall review of their progress at ward rounds. Staff provided information about possible side-effects. Patients were involved in discussions about medication and care planning. However, 1 patient told us they had requested different medication that had been declined, and 1 told us they had requested a second opinion appointed doctor (SOAD), but this was not fulfilled. When reviewing medication charts, we did see evidence of SOAD reviews.

Staff stored and managed all medicines and prescribing documents safely. All medicines were stored in locked cabinets, or in the medicine fridge in the clinic room.

Staff completed medicines records accurately and kept them up to date. Medication charts were electronic, easy to access and included patient photographs for identification, with alerts visible where relevant. Consent to treatment was held separately in a paper‑based folder.

The service employed a pharmacist who visited wards regularly to conduct audits, review medication, prescriptions, and consent to treatment forms.

The service ensured people’s behaviour was not controlled by excessive and inappropriate use of medicines.