You are here

Provider: St Andrew's Healthcare Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 7 January 2020

  • The provider’s leadership team had a comprehensive knowledge of current priorities and plans were in place to address these. Many of these were in their infancy.

  • The provider had not always responded to concerns raised by CQC in a timely manner. Despite board meeting minutes acknowledging inspection findings, we were told of a two-year backlog to address some issues. Board meeting minutes also contained statements which demonstrated senior leaders had not fully accepted the serious nature of concerns raised, or ratings applied, following some inspections.

  • The provider’s systems for sharing learning within and across the organisation were variable and inconsistent. The provider did not have fully effective systems to share learning across different pathways and services. Senior leaders recognised this need.

  • The provider’s recent changes and improvements to the governance structures did not equate to a fully integrated approach at the time of inspection. Staff were able to detail how it would be and when they expected to have an integrated governance dashboard in place. There was minimal evidence of scrutiny or challenge, to either corporate or clinical governance, being delivered by the non-executive directors at governance committees.

  • There was a lack of clarity regarding operations and governance processes taking place in the same committees and whilst the staff believed it worked currently, there was a potential risk of conflict of interest, as best practice and policy development could be influenced by operations managers. The provider may wish to consider separating governance and operations at the highest level to mitigate the risk for potential conflict.

  • The link between the risk register and strategic assurance framework (SAF) was unclear from those we spoke to during the well led review. The escalation process between ward and integrated practice units (IPU) and then IPU to clinical governance, and upwards to the charity executive committee, were also unclear. Ongoing development of these structures was noted.

  • The provider had robust systems and processes for monitoring compliance with the Mental Health Act.

  • The board reviewed performance reports that included data about the services, which included an integrated clinical governance report. An integrated performance report was under development and near completion.

  • The provider had made improvements in IT systems and infrastructures which lay the foundations to fulfil larger plans.

  • The provider was actively engaged in collaborative work with external partners, to share and learn, network, and work in partnerships with a focus on looking at gaps in treatment pathways for people struggling with their mental health.

  • There were various mechanisms for staff to feedback and engage. As the culture evolved staff were using these more.

  • The provider was committed to improving services by learning from when things go well and when they go wrong, promoting training, research and innovation.

  • The provider had invested in a research team with an allocated budget and a focus on research projects that were practical and meaningful to care, and services provided.

  • Staff did not consistently feel confident to raise concerns without fear of reprisals. The provider had not afforded the appropriate protection to one staff member under The Protected Disclosures Act 2014.

  • The mortality report did not evidence a robust and comprehensive analysis of mortality and lessons learned.

  • Mental Health Act governance did not include regular reporting to the board. This was only done through exception and was not a routine report. Therefore, there was a risk the board may not be fully sighted of all concerns identified, for example from Mental Health Act review reports. The Chief Nurse provided information and allocated responsibility to relevant teams, in-line with processes for CQC actions. The assurance and appraisal of Hospital Managers needed to align to the Mental Health Act requirements.

  • The provider had not yet embedded a formal and consistent approach to quality improvement. Audit activity was undertaken by both a quality team and clinical audit. There appeared to be confusion between audit and quality improvement. A formal and consistent approach to quality improvement was yet to be embedded. It was recognised that revised governance structures required further development prior to launching formal quality improvement. Innovations were still encouraged following a plan-do-study-act (PDSA) methodology including body worn cameras, reducing restrictive interventions, and admission projects.


  • The provider had a newly formed leadership team with many of the skills, abilities, and commitment to provide high-quality services. There was now a clearer focus on clinical leadership, alongside an identified need to further define and develop the assurance function within a non-executive director/governor role.

  • We recognised that the appointment of a chair, through a robust external process, had paved the way for future non-executive director recruitment and engagement.

  • Senior leaders were visible and approachable. The provider had a programme of visits to all services.

  • The board and senior leadership team had a clear vision and set of values that were at the heart of all the work across services. They were working hard to make sure staff at all levels understood them in relation to their daily roles. There was an authentic desire to live the values and embed these within the recruitment process to build a robust and consistent culture.

  • The provider’s work around staff wellbeing, development, and recruitment and retention were recognised as strengths and were having a positive impact. Examples included opportunities for support workers to complete nurse training, vicarious trauma teams, and recruitment assessment centers were recognised as strengths and were having a positive impact.

  • The provider promoted equality and diversity in their day to day work and when looking at opportunities for career progression.

  • The provider had developed and embedded data systems, which were showing early promise to give greater oversight of issues facing the provider. The safety framework dashboard was underpinned by a good process and ability to illustrate trends and graphs by facility and by group.

  • Incidents of staff use of physical restraint of patients were increasing. The provider had a reducing physical interventions plan but, at the time of inspection, this had not led to a reduction in restraint incidents.

  • The provider’s process for recording and monitoring duty of candour requirements was not fully effective. We found some discrepancies between the duty of candour register and the details in the quality report. We were aware of plans for review of policy and process.

Inspection areas


Requires improvement

Updated 7 January 2020



Updated 7 January 2020



Updated 7 January 2020



Updated 7 January 2020


Requires improvement

Updated 7 January 2020