Althorp Grange

Updated 11 December 2025

At this assessment we assessed 1 assessment group; Long stay or rehabilitation mental health wards where we assessed 33 quality statements.

Staffing deployment was inconsistent. Staff didn’t always provide care when people needed it. Medicines weren’t always managed safely. Risks weren’t always identified or managed properly. Some maintenance repairs weren’t fixed, affecting safety and comfort. Staff safeguarding knowledge improved, but safety was still inconsistent.

Staff assessed physical and mental health needs and followed national guidance. Teams worked well together, and most care plans were person-centred. Some care plans lacked personal detail. Activities were often cancelled due to staff shortages, affecting people’s independence and recovery goals. Staff understood the individual needs of people and supported people to understand and manage their care, treatment or condition. People weren’t always treated with dignity due to delays and restrictive care. Leaders didn’t always respond properly to legal concerns. Monitoring tools were used, but leadership gaps affected outcomes

Staffing shortages meant care wasn’t always person-centred. People weren’t always involved in decisions about their care. Communication during the hospital’s transition caused confusion. Complaints weren’t used well to improve the service.

Leaders were visible and approachable. Frequent management changes caused confusion. Some leaders didn’t understand legal duties around Mental Capacity Act and Deprivation of Liberty Safeguards leading to breaches. Governance improved but audits and complaint learning were weak. Staff rotas were poorly managed. New systems like Freedom to Speak Up were introduced, but leadership issues remain.

At this assessment we identified breaches of regulation: Regulation 12. Safe Care and Treatment, Regulation 13. Safeguarding, Regulation 15. Premises and Equipment, Regulation 17. Good governance. Regulation 18. Staffing. We asked the provider for an action plan in response to the concerns found at this assessment.

Why we carried out this inspection.

We assessed the service to review the progress made following the assessment in April 2024. At that assessment the overall rating was requires improvement, the effective key question was inadequate. Safe, caring, responsive and well-led were rated as require improvement. Because of repeated breaches from July 2023 assessment for regulation 9 person centred care, regulation 10 dignity and respect, regulation 12 safe care and treatment and regulation 17 good governance; the service was placed in special measures.

Following the 2024 assessment, we issued action plans for breaches of regulations 9, 10, 12, 17. We identified breaches of regulations in relation to staff not ensuring that all service users were fully involved in the development and ongoing monitoring of their care plans; leaders not ensuring that staff treated service users with kindness, privacy, dignity, respect, compassion, and support at all times; leaders not ensuring care and treatment was provided in a safe way; leaders not ensuring access to Freedom to Speak Up structures and support, a lack of robust governance systems.

However, we found some improvements with staff involving most people in their care plans, positive behaviour support plans and discharge and recovery plans, including wellness recovery action plans. Leaders initiated Dignity champions across the wards to better support people; leaders addressed Freedom to Speak Up structures and support with an outside agency with two Freedom to Speak Up champions for the hospital. The provider had improved multidisciplinary and interagency working.

This service has been in special measures since July 2023. The provider’s responsiveness to concerns in relation to regulation 12 has provided some assurance, so we will be issuing action plans in relation to these breaches. The service is no longer rated as inadequate under the key question Effective. Therefore, this service is no longer under special measures.

Mental Health Act and Mental Capacity Act Compliance Summary

Mental Health Act

• Staff had access to Mental Health Act policies and procedures and the Code of Practice.
• The provider had access to Mental Health Act administrative support and legal advice on implementation of the Mental Health Act.
• Staff received training in the Mental Health Act. The training compliance rate was 99% and most staff had a good understanding of the Mental Health Act, the Code of Practice and the guiding principles.
• Staff could give examples of how to protect people from harassment and discrimination, including those with protected characteristics under the Equality Act.
• Care plans referred to identified Section 117 aftercare services to be provided for those who had been subject to section 3 or equivalent Part 3 powers authorising admission to hospital for treatment.
• Staff stored copies of people detention papers and associated records (for example, Section 17 leave forms) correctly and so that they were available to all staff that needed access to them.

Mental Capacity Act

• Staff had received training in the Mental Capacity Act and Deprivation of Liberty Safeguards with staff training compliance rates at 98%.
• Leaders did not support one patient in line with the Mental Capacity Act to ensure they received care in and support in the least restrictive way. The patient’s authorisation expired on 29 April 2025, and an application for a further assessment had been submitted to the placing authority on 24 April 2025 and reapplied for on 6 June 2025. The patient was experiencing significant restrictions, living -in long-term segregation with minimal adjustments made to their care and support. This was raised with the provider and action taken following the inspection to explore less restrictive ways to support the patient.
• There were 10 Deprivation of Liberty Safeguards applications made in the last 12 months, one application approved and 9 awaiting approval, to protect people without capacity to consent when being deprived of their liberty.
• The provider had a policy on the Mental Capacity Act, including Deprivation of Liberty Safeguards.
• The provider engaged Independent Mental Capacity Advocates (IMCAs) to support some people during decision-making about their care and living arrangements, ensuring their rights and preferences were considered.
• For people who might have impaired mental capacity, staff assessed and recorded capacity to make decisions about care and treatment appropriately. They did this on decision-specific basis with regard to significant decisions. However, for one patient, the Mental Capacity Act assessments lacked sufficient detail to demonstrate legal compliance, particularly in relation to decision-specific capacity and best interest determinations. Following on the inspection the provider addressed this and engaged an Independent Mental Capacity Advocates to support the patient with the process and reviewed patient care, with segregation assessments, decision specific assessments and best interest decisions.
• The provider did not consistently demonstrate good understanding of the Mental Capacity Act. Leaders had not been responsive in following up one patient deprived of their liberty with an application to authorise this deprivation. This was raised with the provider, and they took immediate action following on the inspection. However, staff made Deprivation of Liberty Safeguards applications when required and monitored the progress of applications to supervisory bodies.
• The provider’s audit timetables did not include audits for the application of the Mental Capacity Act and Deprivation of Liberty Safeguards tracker.

Updated 28 July 2025

We completed an assessment and inspection of Broomhill hospital from 19 to 20 August 2025. At the time of our assessment the service was called Broomhill hospital. Following the August assessment on 2 October 2025, the service was renamed Althorp Grange and is now part of adult social care provision.

This assessment was carried out following CQC’s new approach to assessment; Single Assessment Framework (SAF). We looked at all the quality statements under each key question. This was an unannounced assessment, which meant the provider was not told an assessment was going to take place.

Broomhill hospital provides care, treatment, and support to individuals with mental health concerns. Broomhill is part of St. Matthews Limited, which consists of 4 care homes and 4 hospital locations in Northampton and Coventry. Broomhill is registered to provide 99 beds across one assessment service group (ASG). Long stay rehabilitation for adults of working age consists of 3 wards with a total of 27 people at the hospital. This assessment looked at the long stay rehabilitation wards known as Cottesbrooke a female ward, Kelmarsh and Lamport, both male wards. There is 15 bed step-down service funded by another provider with no people using the service at the time of our assessment. A step-down service is a temporary short-term service that provides an environment for people transitioning from acute hospital settling back into the community, care home or their own home.

Broomhill hospital provides long stay or rehabilitation mental health wards for working adults. The service did not have a registered manager at the time of our assessment but had an acting manager awaiting CQC registration.

Broomhill hospital was registered with CQC in April 2012 to deliver the following regulated activities:

• Assessment or medical treatment for people detained under the Mental Health Act 1983
• Treatment of disease, disorder or injury.

Updated 28 February 2024

Our rating of this service went down. We rated it as inadequate because:

• The ward environments were not safe. The provider had not identified appropriate mitigation for identified ligature risks. Staff could not always observe patients in all areas of the wards due to blind spots. The provider had not ensured that the hospital’s policy on patient observations reflected the National Institute for Health and Care Excellence guidelines.
• We saw two incidents where staff had not restrained patients in line with hospital’s policy. Patients did not have access to a de-escalation room.
• We found that staff had not maintained the safety of all patients, ensuring that patient safety risks (including allergies and sexual vulnerability) were safely managed. Staff had stored plastic bags in the drawer on Althorp ward.
• Wards were not clean or well maintained. We found dirty and damaged furniture and fittings.
• taff had not checked and cleaned medical equipment regularly or ensured that clean stickers were in place. There was no evidence that medical equipment had been calibrated regularly. Regular checks of access to emergency grab bags and defibrillators had not taken place.
• Staff had not conducted risk assessments in line with the hospital’s policy and procedure for the use of bed rails had not been fully adhered to.
• Staff had not always undertaken non-contact observations post rapid tranquillisation, when patients refused to have their physical health observations undertaken.
• Staff were not always adhering to the hospital’s infection prevention and control policy. Some staff were not bare below the elbows, and we observed that some staff were wearing earrings, watches, and other jewellery. We found that staff had not safely stored food and drink on the ward. Food items had been left out of the fridge and there were undated items which had been transferred into plastic containers.
• Not all patient medicines had been included within the patient’s consent to treatment form. Some patient medicines had not been prescribed within BNF limits.
• The provider did not have fully effective governance structures and processes to provide oversight and assurance of all aspects of service delivery, to be able to identify and improve practice in a timely manner and sustain that improvement.
• Staff had not fully met all mandatory training requirements.
• The service did not work to a recognised model of mental health rehabilitation. Staff had not supported all patients (where appropriate) in finding opportunities for education and employment.
• The provider had not ensured that all patient activities on the ward had been fully risk assessed including potential risks relating to other patients.
• Staff had not always treated patients with compassion and kindness or respected their privacy and dignity. They had not actively involved patients and families and carers in care decisions. Patients had not been fully involved in the development and ongoing monitoring and given a copy of their care plan.

However

• Staff knew how and where to access ligature cutters.
• Most patients told us they would tell staff if they had any concerns.
• Staff were aware of their individual responsibility in identifying any individual safeguarding concerns and reporting these promptly.
• The provider used a recognised risk assessment and risk management tool.
• The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.
• Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. The provider had effective processes for the management and recording of Mental Health Act paperwork.
• There was good access to the garden areas and fresh air.