Northamptonshire Healthcare NHS Foundation Trust

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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 requires improvement. At this assessment the rating has changed to Good. This meant people were safe and protected from avoidable harm.

The ward was consistently safe, clean, and well maintained, providing an environment that was fit for purpose. It was equipped and furnished to a high standard.
Staff demonstrated effective risk assessment and management for both patients and themselves. They had a clear understanding of safeguarding responsibilities and worked collaboratively with external agencies to protect patients from harm. Robust systems and processes were in place to ensure medicines were administered, recorded, and stored safely. Patient safety incidents were managed appropriately, with learning shared to improve practice. Patients received support from staff who were familiar with their individual needs and implemented effective risk management strategies.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We scored the service as 3. The evidence showed a good standard. 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.

Staff demonstrated a proactive and positive culture of safety that was rooted in openness and honesty. In the last 12 months there had been one serious incident, involving a bite injury to a member of staff, as well as occasional minor medication errors. These were fully investigated, did not show any ongoing pattern, and were used as opportunities for learning. Families confirmed they were informed and offered explanations when things went wrong. Staff also described incidents such as unexplained bruising identified on admission, which were documented on body maps, discussed with families, and reported via the Trust’s Datix system (the electronic system used to record and manage incidents). These responses showed that adverse events were taken seriously and managed appropriately.

Staff were clear about what incidents should be reported and how to report them. Staff consistently referred to risk management system and reflective accounts, with oversight from the ward manager and senior staff. They confirmed that all incidents which required reporting were raised, and the service promoted a no-blame culture that encouraged openness and learning. Staff understood their responsibilities under the duty of candour and described being transparent with families when things went wrong. They gave examples of contacting relatives promptly to explain events and reassure them of the actions being taken.

Staff received feedback from investigations of incidents, both from internal reviews at team meetings and through external trust wide audits such as medicines, handwashing and record-keeping. Staff explained that lessons learned were discussed during team meetings and safeguarding discussions, and that these opportunities were used to reflect on what went well and what could be improved. The service was able to demonstrate that changes had been made because of feedback, including the introduction of record-keeping audits to strengthen documentation, embedding new processes to ensure all annual health checks were completed, and reassessing competencies following minor medication errors.

Improvements in safety were specific to the service and focused on strengthening reflective practice and competency checks. The culture of continuous improvement meant that safety issues were identified, shared and addressed quickly. Staff confirmed that they were debriefed and supported after incidents, which helped embed learning while also maintaining staff wellbeing.

We work with people and our partners to establish and maintain safe systems of care, in which safety is managed, monitored and assured. We ensure continuity of care, including when people move between different services.

Quality Statement Score: 3

We scored the service as 3. The evidence showed a good standard. 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 are discharged back home.

The service had clear and structured referral and admission processes which ensured that all essential information about patients was received prior to admission. Pre-admission assessments were undertaken with input from families, carers and GPs to confirm that the service could meet the individual’s needs safely. These assessments included consideration of health conditions such as epilepsy, swallowing difficulties, and behavioural risks, and they were reviewed and updated at each admission to reflect any changes in the person’s needs. Where people required reasonable adjustment and had advance care plans, such as Do Not Resuscitate (DNR) instructions, these were appropriately documented and incorporated into individual care records.

Staff worked closely with families, healthcare and social care partners to ensure continuity of safe care throughout the patient’s journey. Patients were required to be assessed for and funded through Continuing Healthcare (CHC) before accessing respite placements, and staff liaised with local CHC teams to confirm eligibility and ongoing support arrangements. Care planning was completed in partnership with carers and external professionals, ensuring that important information was shared and embedded into support plans. Staff gave examples of working alongside speech and language therapy services, community nursing teams and GPs to ensure continuity of care for patients with complex needs such as dysphagia and epilepsy.

Continuity of care was also maintained post-discharge. Patients returned home following respite stays with clear care records, and staff ensured that families were fully involved in handover discussions so that risks and care strategies remained consistent. Staff described how multidisciplinary input, Occupational Therapist/Healthcare Assistant dual-working across community and service, was integrated to strengthen the pathway between community and inpatient support.

We work with people to understand what being safe means to them as well as with our partners on the best way to achieve this. We concentrate on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect, and we make sure we share concerns quickly and appropriately.

Quality Statement Score: 3

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They focused 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 and demonstrated a good understanding of how to protect people from abuse, neglect and discrimination. Staff had completed safeguarding training appropriate to their role. Senior staff, such as ward managers and team leaders (Band 6 and above), had completed Level 3 safeguarding training, which covers leading investigations and making complex safeguarding decisions. Other staff, such as registered nurses and support workers (Band 5 and below), had completed Level 2 safeguarding training, which focuses on recognising and reporting concerns.

At the time of inspection, there was one Band 6 nurse in post, who was booked to attend Level 3 safeguarding training on 6 October 2025. Level 3 training is required for Band 6 and Band 7 roles only, reflecting their responsibility for managing safeguarding processes. The provider told us that following the inspection, all Band 6 and 7 staff have now completed the required Level 3 Safeguarding training, with compliance reported as 100%.

Staff confirmed that safeguarding was a regular agenda item at team meetings and gave examples of raising concerns in relation to bruising or the use of equipment. They described following appropriate processes, including completing body maps, informing families, recording concerns on risk management system, and escalating to the ward manager or nurse in charge. Staff were confident that they knew how to make a safeguarding alert and had done so when appropriate. They worked in partnership with external safeguarding structures and confirmed that local teams were approachable and responsive. Records showed there had been no safeguarding alerts raised in the last 12 months.

Staff were also able to give examples of how they protected people from harassment and discrimination, including those with protected characteristics under the Equality Act. The workforce reflected diversity, and the ward manager emphasised equality and inclusion within the team. Families told us they felt their relatives were safe and well supported.

The safeguarding culture was supported by a diverse staff team and consistent engagement with families. One carer told us: “We appreciate the check in calls 24 hours before admission.”

Restrictive interventions were not routinely used within the service. Staff said there was no use of physical restraint or seclusion, and instead they relied on proactive de-escalation and detailed knowledge of people’s needs. Where restrictions were necessary, these were proportionate, individually risk-assessed, and aligned with the Mental Capacity Act (MCA).

Staff had completed mandatory training in the Mental Capacity Act, and staff demonstrated a good understanding of how to apply the five statutory principles in practice. While not all staff were able to recall the principles in detail, they were able to describe how these were embedded in day-to-day care. This provided assurance staff were applying the principles effectively. Mental capacity assessments were carried out by the community team as part of annual health checks for all patients who lacked capacity, and these were updated on admission. Staff explained that capacity to consent was assessed on a decision-specific basis, particularly for significant decisions regarding physical health. For those who lacked capacity, decisions were made in their best interests, considering the person’s wishes, feelings, cultural background and history.

The provider had clear policies on the Mental Capacity Act and Deprivation of Liberty Safeguards (DoLS), which staff were aware of and knew how to access. Staff knew where to obtain advice within the Trust if needed. Applications for DoLS were made when required, and monitoring processes were in place. Staff described that the service had arrangements to monitor adherence to the Mental Capacity Act, with audits completed to ensure compliance.

We work with people to understand and manage risks by thinking holistically so that care meets their needs in a way that is safe and supportive and enables them to do the things that matter to them.

Quality Statement Score: 3

We scored the service as 3. The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. Staff assessed and managed risks to patients and themselves well and followed best practice in anticipating, de-escalating and managing challenging behaviour. The ward staff participated in the provider’s restrictive interventions reduction programme. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The service promoted people’s rights to make decisions wherever possible. While most patients lacked capacity, staff sought to involve them in decision-making to the extent they were able and recorded their wishes and preferences in care plans. Where people lacked capacity, families were engaged, and decisions were made in the person’s best interests. Patients and carers had access to advocacy services to support them in expressing their views and wishes.

Not all patients could communicate their needs directly, so staff worked closely with carers to identify risks and tailor support. Staff were trained in Positive Behaviour Support (PBS) and de-escalation techniques and gave examples of anticipating triggers, using distraction, and providing sensory support to reduce distress.

Risk assessments were individualised, reviewed at least six-monthly, and updated following incidents. Carers were involved in reviews, ensuring shared understanding of risks. Families told us staff “always listen” and involve them in decisions.

However, 2 staff member acknowledged that continuity could sometimes be affected when bank staff were covering shifts, as not all were equally confident in-patient communication methods. Leaders mitigated this by only using regular bank staff familiar with the ward and reinforcing induction processes.Staff described this approach as ensuring familiarity and continuity for people using the service.

We reviewed 6 risk assessments and care plans. These were all up to date, person-centred and clearly demonstrated how staff worked with families and carers to identify and manage risks. All patients had a pre-admission risk assessment, updated on each admission, with input from families, carers and GPs. Risk management plans included areas such as epilepsy management, swallowing difficulties, behavioural triggers and the use of specific equipment.

Staff involved patients and their families in care planning and risk assessment. Care plans were developed jointly with carers to reflect routines, communication needs and preferences. Patients were supported in ways appropriate to their level of understanding, and staff communicated with individuals using personalised approaches. For patients who were non-verbal or had high communication needs, staff worked with families to ensure their preferred methods of communication were embedded in care plans and daily practice.

Patients and families were encouraged to give feedback on the service through surveys, electronic systems and direct discussions with staff. Families confirmed they felt listened to and involved in decisions about their relative’s care. Staff also described involving carers in transition planning and reviewing risk management strategies to ensure continuity of safe support when patients returned home.

We detect and control potential risks in the care environment and make sure that the equipment, facilities and technology support the delivery of safe care.

Quality Statement Score: 3

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

The environment was clean, well maintained and supported safe care. Bedrooms and bathrooms were in good condition, communal areas were tidy and personalised, and there were visible prompts for hygiene. Fire safety, hoist, and infection control checks were completed every 6 months, and estates staff acted promptly when issues were identified.

Additionally, there was initially no formal record of staff training on the safe use of specialist cot beds, although staff reported they had been shown how to operate them. Managers have since confirmed training was completed and provided signed documentation as evidence of compliance.

COSHH materials were stored securely in locked cupboards, and staff had appropriate access to the keys when required. Personal items belonging to people using the service were clearly labelled to prevent misplacement. Individuals were offered the choice to bring their own bedding if they preferred it to the bedding provided by the service, supporting personal comfort and dignity.Staff carried out regular environmental risk assessments to ensure the safety of patients and visitors. The ward manager confirmed that health and safety checks were undertaken every 6 months, covering fire safety, infection prevention and control, and moving and handling equipment. Estates staff also visited weekly to check environmental features, including the function of fire doors, with reports shared back to the manager for prompt action.

The ward layout allowed staff to maintain good oversight of all areas. Access points were managed safely, with the main entrance door kept locked to prevent unauthorised entry from members of the community, who had previously confused the service for a GP practice. Internal doors were individually risk-assessed; clinic rooms were locked when not in use, and keys were kept securely but easily accessible to staff when needed. Closed circuit television (CCTV) was fitted in patient bedrooms. This did not record but was used solely to monitor patient movement in bed. Staff demonstrated good practice in maintaining privacy and dignity by ensuring cameras were switched off during personal care.

Personal Emergency Evacuation Plans (PEEPs) were visible on some patients’ bedroom doors, and all rooms were clearly labelled with the patient’s name. The courtyard provided access to a well-maintained garden that created a pleasant and therapeutic outdoor space.

There were no significant environmental risks identified in relation to ligature anchor points. Where risks were present, these were subject to regular review and mitigation strategies were in place. The ward complied with guidance on eliminating mixed-sex accommodation, with separate bedroom areas and facilities in place to maintain privacy and dignity.

The layout of the ward supported safe observation of patients. Patients were able to call for assistance easily, and staff confirmed that communication systems supported timely responses to need.

The clinic room was fully equipped, containing resuscitation equipment and emergency medicines. Staff said that this equipment was checked regularly in line with Trust policy, and inspection of records confirmed these checks were up to date.

We make sure there are enough qualified, skilled and experienced people, who receive effective support, supervision and development and work together effectively to provide safe care that meets people’s individual needs.

Quality Statement Score: 3

We scored the service as 3. The evidence showed a good standard. The service 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.

The service ensured there were enough qualified, skilled and experienced staff to meet people’s needs safely. Establishment figures showed a requirement of 6.06 WTE Band 5 nurses and 10.06 WTE healthcare assistants (HCAs). At the time of this assessment, one Band 5 vacancy remained on the establishment; however, a candidate had been appointed, and a confirmed start date was in place. There were no HCA vacancies. Staffing turnover remained low, between 4.55% and 9.30% across the past 6 months, well below the provider’s 12% target. Sickness absence ranged between 0.18% and 3.97%, consistently below the 4.6% provider threshold. This demonstrated a stable core workforce with minimal disruption. Families commented that “there are always enough staff” and that staff are “very responsive” to patients’ needs.

Staff rotas showed that the number and grade of nurses and healthcare assistants matched the required establishment. A qualified nurse was present on every shift, including nights, and was visible in communal areas to provide oversight. The ward manager had flexibility to adjust staffing levels daily in line with patient needs and case mix. The standard staffing model was 4 staff for 6 patients. Most staff told us that one-to-one sessions with named nurses were consistently maintained and rarely missed. Occasional short staffing occurred only due to annual leave or sickness, and these gaps were promptly filled by regular bank staff to maintain safe and consistent care. Rotas showed visible Band 7 leadership presence — referring to senior nursing staff responsible for overseeing ward operations and providing clinical and managerial leadership — and staffing gaps were mitigated by using known bank staff rather than agency workers. Managers confirmed bank staff were inducted and supervised to ensure competency.

Analysis of supervision data across the last four quarters demonstrates a generally strong commitment to staff supervision, with compliance rates peaking at 84.2% in Q3 and 90.0% in Q4 of 2024/2025. A “quarter” refers to a three-month period within the financial year, and the Trust uses these quarterly compliance figures as a key measure to gauge how effectively staff supervision is being maintained. During these periods, the number of completed reviews consistently exceeded requirements, reflecting robust oversight and effective management. The requirements for each quarter were as follows: Q3 24/25: 38 reviews required, 40 completed, Q4 24/25: 40 reviews required, 43 completed, Q1 25/26: 42 reviews required, 37 completed, Q2 25/26: 44 reviews required, 23 completed. However, compliance declined to 71.4% in Q1 of 2025/2026, with a noticeable increase in non-compliant staff, and dropped further in Q2, where only 23 reviews were completed against 44 required, making compliance rates unreportable for that quarter. At the time of assessment, the reporting period was still in progress, and staff had time remaining to complete their required sessions before the end of the reporting cycle. The provider explained that full data was not available due to timing; however, they have since confirmed that, by the end of Q2, supervision compliance reached 100%. Importantly, there was clear evidence of managerial oversight, as the ward manager had proactively reminded staff to book their supervision for the current quarter in team meetings. The supervision data reviewed did not explicitly state a Trust target for supervision compliance in each quarter or year. Instead, it reports actual compliance rates and the number of reviews completed versus required.

People were supported to engage in meaningful activities, and where activities were rearranged, this was usually due to patient health needs rather than staffing. Staff also confirmed that there were always enough trained staff to carry out physical interventions when required, although restrictive practices were avoided in favour of de-escalation strategies.

Mandatory training compliance was between 92% and 96% from May to July 2025, with role-essential training 100% by July 2025. Safeguarding Level 3 training had been completed by the ward manager, with the deputy ward manager booked for October. Basic Life Support was up to date for existing staff, with new starters booked for completion in September and October 2025. This demonstrated that staff were trained appropriately for the needs of the patient group.

We assess and manage the risk of infection, detect and control the risk of it spreading and share any concerns with appropriate agencies promptly.

Quality Statement Score: 3

We scored the service as 3. The evidence showed a good standard. 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.

The service had effective systems in place to manage and control the risk of infection. All ward areas were visibly clean, well maintained and appropriately furnished. Staff confirmed that environmental risk assessments, including infection control checks, were carried out every 6 months by the trust. In addition, local audits were completed by the ward manager, and records demonstrated that cleaning schedules were kept up to date.

We observed good infection control practice during the inspection. Bedrooms and bathrooms were visibly clean, cleaning schedules were up to date, and PPE was used appropriately. Family members told us the environment was “the environment is spacious and clean.”

Staff maintained equipment well and ensured it was kept clean. Clinical equipment carried ‘clean’ stickers, which were visible and in date. Staff confirmed they were confident in infection control procedures, and this was supported by mandatory training compliance, which showed infection control training had reached 100% completion by June 2025.

Hand hygiene audits were completed as part of the trust’s mandatory monitoring programme, and staff were observed to adhere to infection prevention principles, including handwashing and the use of protective equipment when appropriate. Estates staff were also seen checking fire doors and environmental safety measures, supporting the safe maintenance of the ward environment.

However, some food items stored in the fridge were found without clear labelling, including missing ‘use by’ and ‘open’ dates. The ward manager acknowledged this and took immediate action to address the issue.

We make sure that medicines and treatments are safe and meet people’s needs, capacities and preferences by enabling them to be involved in planning, including when changes happen.

Quality Statement Score: 3

We scored the service as 3. The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involve people in planning, including when changes happen.

The service ensured medicines were managed safely and in line with national guidance. Medicines were transported, stored and administered following trust procedures. Clinic rooms were locked when not in use, with medicine keys kept securely by staff. Controlled drugs were managed appropriately, requiring 2 qualified staff for administration, and healthcare assistants were competency-checked for their role in supporting safe practice. Staff confirmed that competency assessments for medicine administration were completed annually for nurses and every 6 months for healthcare assistants. Medication errors were rare, and when they occurred, they were reported promptly through Datix, the organisation’s electronic incident reporting system used to record and manage safety events, followed by reflective learning and reassessment of staff competency to prevent reoccurrence.

Medicines reconciliation was carried out for all patients admitted to the service. As a short stay respite unit, most medicines were brought in from home with patients, and staff checked these against care plans and medical records on admission. Recording practices were consistent and medicines were booked in, cross-checked and documented. Disposal of medicines was undertaken in line with trust policy. There was no evidence of inappropriate or blanket use of covert medication. Families confirmed they were kept informed of any changes.

Patients’ physical health was monitored alongside their medication needs. Physical health monitoring was embedded, with checks such as weight and National Early Warning Score 2 (NEWS2) — a standardised system used to identify early signs of clinical deterioration — recorded at admission and throughout stays where appropriate. Staff liaised with GPs and community teams to ensure any changes in treatment were followed up promptly and reviewed in line with NICE guidance.