Northamptonshire Healthcare NHS Foundation Trust

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

At our last inspection in 2023 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 service had a strong culture of safety, with exceptional practice in learning from incidents and involving people in managing risks. Staff were open and honest when things went wrong, investigated incidents thoroughly and shared learning to improve care. People were involved in developing personalised risk management plans, and staff promoted least restrictive practice through trauma-informed care and regular review of restrictive interventions. The service had effective systems for safeguarding, admissions, transfers and continuity of care. Staff managed environmental risks well, maintained safe staffing levels and received appropriate training to support safe care. Infection prevention and control arrangements were effective, and medicines were managed safely, with leaders responding promptly when concerns were identified.

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.

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.

The service had an exceptional learning culture that promoted openness, transparency and continuous improvement. Staff at all levels understood their responsibilities for reporting incidents and were confident to raise concerns. Robust governance systems ensured all incidents received prompt senior oversight, with incident reports automatically shared with ward matrons, service managers and heads of service for daily review and follow-up of any required actions. Learning from incidents, complaints, safeguarding events and patient safety investigations was consistently shared with staff through supervision, training and reflection days, patient safety bulletins and other service-wide communications.

Between 1 December 2025 and 31 May 2026, the service reported 1,289 incidents which were reviewed and grouped by themes. The top 3 themes were self-harm, (318 incidents), followed by violent incidents or assaults (242 incidents), and restrictive practices (210 incidents). Other themes included verbal abuse or threats, absconded or missing patients, and incidents relating to medicines. The service used this information to identify themes and trends across wards and teams. Investigations were completed in a timely way, due to daily incident reviews, and where possible, staff involved patients.

Staff were able to describe how learning from serious incidents across the trust had led to tangible changes in practice and operational policy, including reducing the length of electronic charging cables to minimise risk. Records from staff reflection days showed learning from an unexpected death in the community had resulted in improvements to support for people with co-existing mental health and substance misuse needs, with changes subsequently incorporated into trust policy.

Staff understood and applied the duty of candour and were open and honest when things went wrong. Patients and families were supported to be involved in investigations and were kept informed of progress and outcomes. The service further strengthened learning through the use of body-worn camera footage to support reflective practice, identify training needs and improve responses to incidents. Staff were well supported following incidents through formal debriefs, reflective sessions and access to additional wellbeing support.

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 moved between different services.

The service had effective systems and processes to support safe admissions, transfers and continuity of care. Staff received the information they needed at the point of referral, including people’s mental and physical health histories, current and previous risks, and medicines information. The bed management team reviewed referrals to ensure the service could safely meet people’s needs, with daily meetings held to review referrals and changes in priority.

The bed management team worked closely with ward matrons to plan admissions and maintain oversight of bed capacity. Where staff identified that a proposed admission could not be managed safely, they did not proceed and provided a clear rationale for their decision. Admissions were considered against the proposed ward environment, people’s level of acuity and identified risks to ensure placements were appropriate and safe.

Staff maintained oversight of people placed out of area and worked with multidisciplinary and community teams to support continuity of care and discharge planning. Between December 2025 and May 2026, 36 people were placed out of area across the acute and psychiatric intensive care service. Staff reviewed bed availability, capacity and out-of-area placements daily to identify opportunities to bring people back closer to home as soon as it was safe and appropriate to do so. Leaders worked with health and social care partners to review service provision and reduce the need for out-of-area placements.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They 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 service shared concerns quickly and appropriately.

The service had effective safeguarding systems to protect adults and children from abuse, neglect and discrimination. Staff received appropriate safeguarding training and compliance was above 90% across all wards. Staff knew how to recognise safeguarding concerns and understood their responsibilities for reporting and referring concerns to external agencies, including the Local Authority.

Staff understood how to protect people from harassment and discrimination, including those with protected characteristics under the Equality Act. They followed appropriate procedures when children visited the service to help ensure their safety and wellbeing.

Between 1 December 2025 and 31 May 2026, staff made 48 safeguarding referrals to the Local Authority. Staff worked collaboratively with the Local Authority to ensure safeguarding concerns were appropriately reviewed and investigated. Outcomes demonstrated that concerns were routinely assessed, with action taken where required to reduce identified risks and to protect people from harm. The trust held regular meetings with the Local Authority to discuss safeguarding concerns and ensured appropriate oversight of cases.

The trust had a restrictive practice lead who supported wards to reduce restrictive practices and promoted regular review of restrictions. We reviewed blanket restriction registers, which demonstrated restrictions were proportionate, linked to safety needs and could be adapted to meet individual needs. Governance systems supported ongoing monitoring of restrictions and enabled staff to balance safety with people’s rights and preferences. Staff used emergency restrictive practice forms when short-term restrictions were necessary and removed restrictions as soon as it was safe to do so.

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. Staff used restraint and seclusion only after attempts at de-escalation had failed. 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 had a proactive approach to involving people in managing risks and making decisions about their care. Staff worked collaboratively with patients to identify, review and manage risks, enabling them to remain actively involved in decisions that affected their safety and wellbeing. We reviewed 14 care records and found that each patient had a detailed, personalised risk assessment and risk management / safety plan. Staff reviewed and updated plans, including following incidents. Staff identified risks early and regularly reviewed these. Risk management / safety plans were co-produced wherever possible and reflected patients’ individual needs, strengths and preferences.

Patients were offered copies of their care plans. All patients we spoke with told us they were involved in discussions about risk, care and discharge planning, if they wanted to be. Where a person chose not to engage, staff respected their decision, recorded this and continued to offer opportunities for involvement during regular one- to- one sessions.

The service was committed to reducing restrictive interventions, reviewing incidents and identifying opportunities for improvement. Staff reviewed restrictive interventions with patients following incidents whenever possible. The trust had a restrictive practice lead and each ward had restrictive practice champions. These met regularly and were provided with dedicated development time to promote least restrictive practice and support continuous improvement. Champions had received various training including enabling environments, and how the physical environment can impact upon patients; the importance of a values based approach, and positive social interactions. Senior leaders reviewed every incident involving restraint or seclusion to identify trends, promote learning and reduce the need for future interventions. Between 01 December 2025 and 31 April 2026, the trust reported 320 restraints across all wards. Of these, 29 involved prone restraint (chest down), equating to 9%. Prone restraint had been primarily used to safely administer medicines to patients in distress. Records demonstrated staff used this intervention only when necessary and supported patients out of the position as soon as it was safe to do so.

Staff delivered trauma-informed and psychologically safe care and continuously sought to minimise restrictions on patients. Between January and May 2026, staff had nursed patients in seclusion on 70 occasions across all wards. Staff regularly reviewed patients in seclusion and looked to end episodes at the earliest opportunity, supporting patients to return to the ward as soon as risks had reduced. Seclusion episodes ranged from 30 minutes to 217 hours, reflecting individual patient circumstances and levels of risk. Rapid tranquillisation had not been used on the wards visited in the weeks preceding our assessment. Staff told us this intervention was only used as a last resort in exceptional circumstances to maintain safety.

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 service provided a safe environment that supported the wellbeing of patients and staff. Staff completed daily environmental checks on each ward and promptly escalated any concerns to the relevant teams. Information about environmental risks and required actions was shared during staff handovers to help maintain patient safety.

Staff were able to observe most areas of the wards and used additional measures where visibility was reduced. Convex mirrors were installed in identified blind spots and staff used enhanced or strategic observations when patients or environments presented increased risks.

The wards had anti-ligature fittings where possible and staff managed identified environmental risks effectively. Each ward had an up-to-date ligature risk assessment, supported by visual ward heat maps that highlighted higher-risk areas. Staff knew how to access ligature risk assessments and the location of ligature cutters. Managers reviewed ligature risk assessments annually and all identified risks had clear mitigation plans in place, including increased staff supervision where required.

The service complied with guidance on eliminating mixed-sex accommodation. Staff had access to personal alarms and communication systems to summon assistance when needed, and patients could use nurse call systems to request support. Clinic rooms were fully equipped with emergency equipment and medicines, which staff checked regularly to ensure they were fit for use.

Designated seclusion rooms met the requirements of the Mental Health Act Code of Practice, including facilities for observation, two-way communication, toilet access and visible clocks. Although there were faults with two communication systems at the time of assessment, leaders addressed these immediately. No patients were being cared for in the rooms at that time.

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 had enough suitably skilled staff to provide safe care and treatment. Leaders monitored staffing levels closely and took appropriate action to minimise the impact of vacancies and sickness absence on patient care. In April 2026, there were 17.41 whole-time equivalent clinical staff vacancies and 9,32 Registered nurse vacancies. The trust had successfully recruited to 12 of these posts and continued to actively recruit into the remaining roles. To maintain continuity of care, staffing gaps were covered by regular bank staff who were familiar with the wards and patient group.

Leaders managed staffing pressures effectively and ensured patients continued to receive safe care. Staff sickness across the wards had varied over the previous 6 months and had ranged between 0.5% and 12.8%. Data highlighted there were some wards with higher sickness rates (Avocet and Kingfisher). At the time of our assessment, there were staff off with long term sickness and 3 short term absences. Reasons for sickness included physical health, mental health, and surgery. Regular bank staff were being used to cover sickness absence. No agency staff were used.

Staff told us there were generally enough staff on duty to meet patients' needs and patients spoke positively about the availability and support provided by staff. Ward matrons requested additional staffing when required, including to support patients attend appointments or to manage increased levels of risk. Therapy staff, ward matrons and physical healthcare teams were supernumerary and provided additional support to maintain safe ward environments when needed. Between December 2025 and May 2026, there were 16 occasions where staffing fell below safer staffing expectations. However, these were managed safely using supernumerary staff and support from neighbouring wards. Of the 18 patients we spoke with, 2 commented that additional staff would be helpful at times for people who needed extra support, or to further support with patients leave. Sixteen patients said there was enough staff on duty.

Staffing levels supported the delivery of therapeutic care and treatment. Patients were able to spend one-to-one time with their named nurse, and staff shortages rarely resulted in cancelled escorted leave or ward activities. Of the 18 patients we spoke with, one patient said if the Occupational therapist was off, groups would not always go ahead. Another patient said there was a lack of activities over the weekends.

Staff received training in physical interventions and there were sufficient staff available to undertake these safely when required. The trust ensured staff maintained the skills and knowledge needed for their roles. Compliance with mandatory training was between 90% and 95% across all wards. Staff also completed role-specific training, including training relating to the Mental Health Act and Mental Capacity Act, with overall compliance of 94%.

The service had appropriate medical cover during the day and night, with doctors able to attend promptly in an emergency.

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 and processes in place to prevent and control infection. The hospital environment was clean, well maintained and suitable for the needs of patients. During our assessment, we found wards, clinic rooms, bathrooms and toilet facilities clean and tidy. Furnishings were in good condition. Carers told us the wards were consistently clean and well presented.

Housekeeping staff supported the maintenance of a clean environment and followed cleaning schedules to ensure all ward areas were cleaned regularly. Patients had access to ensuite bathroom facilities and there were appropriate hand-washing facilities across the wards. Hand hygiene information was displayed to promote good practice among staff, patients and visitors.

Staff understood their responsibilities in relation to infection prevention and control (IPC). All staff were up to date with IPC training and had access to specialist advice through the trust’s IPC team. Each ward also had an IPC champion to support good practice and provide local oversight.

Staff followed safe food hygiene and storage procedures. They completed routine temperature checks of food storage areas and checked hot food temperatures before serving to ensure food was stored and prepared safely. Chemicals and cleaning products were stored securely in line with safety requirements.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

The service had effective systems and processes to support the safe management and optimisation of medicines. Staff followed good practice in the prescribing, storage, administration, reconciliation and disposal of medicines and worked in line with national guidance and trust policies. During our assessment, we identified some medicines awaiting collection from controlled drug cupboards for longer than expected. Several staff explained they were having to undertake additional checks, which could be avoided had they been collected. We fed this back to the trust who acted immediately, with all relevant items being removed.

Staff completed medicines reconciliation before admission and gathered comprehensive medicines information at the point of referral, including current and previous prescribed medicines. Ward staff and pharmacy teams worked collaboratively to maintain oversight of medicines stock and support the safe use of medicines across the service. Clinical staff had access to the equipment needed to undertake physical health monitoring and managers ensured equipment was calibrated and maintained appropriately.

Staff monitored the use of medicines and reviewed patients regularly to ensure medicines remained safe and effective. We found no evidence of prolonged or excessive use of medicines prescribed on an ‘as required’ basis without medical review. Between January and March 2026, rapid tranquillisation (RT) had been administered on 25 occasions across the service. Patients had been offered oral medicines before administering RT. Staff routinely completed physical health observations following administration. Where patients had declined observations, staff recorded visual observations and continued to monitor their wellbeing.

Staff reviewed the effects of medicines on people’s physical health in line with national guidance, including for patients prescribed higher-risk medicines requiring additional monitoring. Care records included clear plans detailing the monitoring required. Staff completed physical health observations as expected, in line with care plans. Staff reported medicines-related incidents and took appropriate action when concerns were identified. There were no identified themes or patterns in medicines errors reported between December 2025 and May 2026.