Althorp Grange

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 requires improvement. At this assessment the rating has remained requires improvement.

Staffing deployment was inconsistent, and people did not always receive care when they needed it. Managing medicines wasn’t always carried out properly, which could put people at risk. Risk assessments were not always completed consistently, so some risks had not been properly identified or managed. Some repairs and maintenance issues had not been fixed, which could affect people’s comfort and safety. Some people did not receive care in the least restrictive way because the Mental Capacity Act wasn’t always followed. This led to delays and affected their dignity. Staff demonstrated improved understanding of safeguarding procedures; however, safety assurance across the service remains inconsistent.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

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 when people moved between different services.

The multidisciplinary team were well resourced and included 2 clinical psychiatrists, 2 junior doctors, a psychology lead and 3 psychology assistants and one locum occupational health lead and 2 occupational health assistants. The multidisciplinary team worked to well to develop joint assessments and discharge planning.

We observed multidisciplinary teams and services worked well together at the monthly ward round. Staff were preparing people to transition to appropriate services. Staff and local teams attended including care coordinators, hospital leads, community health teams and advocates. They met to review each patient’s readiness for transition. Some people were at the beginning of finding appropriate placements; whilst other people were already transitioning to another service with planned visits and overnight stays in place.

We observed staff providing updates from people’s discharge and recovery plans, including wellness recovery action plans, and positive behaviour support plans. Staff co-produced these plans with most people. We observed one patient’s family member were virtually involved in the ward round and spoke on behalf of their family member. They said their relative would be unsettled during a move to another service. The psychologist agreed to provide psychology sessions including mindfulness to help support their relative through the transition.

We observed during ward rounds the advocate worked alongside clinical teams to ensure people’s views were considered in decisions about appropriate transition plans.

The service assessed and managed the risk of infection, detected and controlled the risk of it spreading, and took prompt action where additional cleaning was required.

Staff maintained equipment well and kept it clean. Any ‘I am clean’ stickers were visible and in date.

The wards were clean. The housekeeping team worked 7 days a week. Cleaning records were up to date and showed ward areas were cleaned regularly. Bedrooms were scheduled for deep cleaning on a rotating basis.

Following the last inspection in April 2024, the provider appointed an infection prevention compliance lead to oversee and improve infection control practice across the hospital.

Infection prevention and control training compliance was 91%. The expected compliance rate was 90% and above. There were no further Infection prevention and control training dates planned.

An infection control audit was carried out in March 2025 with a 97% compliance score. An action plan summary confirmed follow up action for Cottesbrook ward only regular deep clean on all areas of the ward on to be completed weekly in August 2025.

Staff worked to infection control principles, including handwashing. The exception was in Cottesbrook clinic room ward where we saw thick dust and no disposable gloves available. The provider was responsive, and the clinic room was immediately cleaned, and disposable gloves replenished the same day.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Areas in one clinic room were not maintained in line with good practice.

People usually received their medicines safely and as prescribed. Staff generally followed good practice in medicines management (that is, transport, storage, dispensing, administration, medicines reconciliation, recording, disposal, use of covert medication) and did it in line with national guidance.

During the Cottesbrooke clinic room check staff didn’t know where the medicine policies were and didn’t know the policies and procedures for medicines used to support people feeling anxious or distressed with sleeping or controlled drugs. We observed a used needle (used to inject medication under the skin) left on top of the needle disposable container. Staff had not followed correct procedures to ensure used needles were disposed of safely. The medicine container to dispose of used medicines was overflowing. There were 4 missing entries in the medicine fridge temperature records between June and August 2025. It’s important that fridge temperatures are recorded consistently to ensure medicines are stored safely.

There were missing signatures in the controlled drugs stock check for one person for morphine sulphate liquid. The provider treated this medicine in line with controlled drugs procedures. Staff told us there were weekly audits of controlled drugs by the pharmacy with the findings sent to managers and had not been picked up.

We saw on display British National Formulary (BNF) book dated Sept 2022 to March 2023. British National Formulary contains key information on the selection, prescribing dispensing and administration of medicines and is updated yearly. Staff were unaware the British National Formulary was available online and on the providers intranet. This meant staff were not accessing the most up to date prescribing information available. However, we received immediate assurance the same day of inspection that improvements were made to the areas identified by CQC.

We carried out 2 clinic room checks on Lamport and Cottesbrook ward. Both clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly.

Staff reviewed the effects of medication on people’s physical health regularly and in line with NICE guidance, especially when the patient was prescribed a high dose of antipsychotic medication. Doctors monitored people’s high dose and anti-psychotic treatments every three months. This included full blood checks, liver functions, urine electrolyse and electrocardiogram (ECGs). Any concerning results were reviewed with the consultant, and people’s medicines were adjusted accordingly.

The provider reported 5 incidents of medicine errors to CQC during June 2025; however, these incidents did not lead to people being harmed. Provider monthly medicine audits showed low level issues identified with the last audit completed on 8 July 2025. On Cottesbrook checks identified some receipt of stock not being signed and dated and Medicines and Healthcare products Regulatory Agency (MHRA) drug alert checks not up to date. The provider had not checked and logged the alerts on a weekly basis. The provider followed up all these issues with action plans and completion dates for 15 July 2025.

Staff completed safe handling of medicine training with the compliance rate at 95%. Medication competency frameworks were completed annually to ensure staff remained up to date with safe mediation management. Following the last inspection in April 2024 a ‘Medication Optimisation’ director was appointed to improve medicines management. However, there were limited improvement around medicines management.