St Andrews Healthcare Northampton

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

We identified some areas of concern under the safe key question which will require an action plan. We saw that clinical staff undertook ligature risk assessment across all wards, but the provider was unable to demonstrate that staff had completed relevant training to complete this task, or that staff were aware of the risks. Emphasis was placed upon learning from incidents to improve practice. Staff told us they could and would raise concerns with senior staff. Staff reported and investigated safety events and incidents; however, staff told us that risks they identified associated with staffing and use of non-ward-based staffing were often not taken on board by managers, and that raising concerns had not always helped to proactively identify and manage risks before safety events happened. For example, Patients were not always being nursed under the prescribed levels of observation. Staff had to be taken off patient observations, to attend to patients’ personal care. These changes to patient observations had not been formally risk assessed, which led to the risk of near misses in terms of incidents and harm. Senior leaders told us that staffing was not a concern, however staffing was identified as a concern on the risk register and staff had completed incident reports identifying issues associated with staffing levels. Staff had a good understanding of safeguarding and took appropriate actions. There were systems and processes in place to ensure people were protected from abuse and neglect. Staff assessed individual patient risks and reviewed these regularly. We found evidence of restrictive practice which had not been individually risk assessed. Leaders continued to work with partners to improve the quality and continuity of care.

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Most patients stated that they knew how to raise a concern and who to speak to if they were unhappy with the service provided. However not all patients and carers were assured that actions were taken at ward level when risks had been identified. We heard concerns from two carers regarding their ongoing concerns relating to the safety of their relative on the wards.

Overall clinical supervision rate for July 2024 was 96%. The lowest overall clinical supervision rate February to July 2024 was in April 2024, when it was 87%. The mandatory training rate for all wards were above 70%. However, non-mandatory training figures below 70% were on Tavener ward (least restrictive practice: 66% and physical health observation foundation skills - 66%), and on Elgar ward (physical health observation foundation skills - 60%). Staff told us that risks they identified associated with staffing and use of non-ward-based staffing were often not taken on board by managers. Patients and staff were encouraged and supported to raise concerns, they felt confident that they would be treated with compassion and understanding, and won’t be blamed, or treated negatively if they do so. However, raising concerns had not always helped to proactively identify and manage risks before safety events happened. Staffing was identified as a concern on the risk register and staff had completed incident forms relating to staff issues. We did however speak with Senior Divisional leaders who detailed a number of changes that had been implemented as a direct result of staff feedback that had a positive impact on staffing levels. Incidents and complaints were appropriately investigated, reported and communicated. However, lessons were not always learned from safety incidents or complaints, resulting in changes that improve care for others. Staff were confident to report incidents however had not always been supported when things had gone wrong. Staff knew what they should report and when. The trust’s formal reporting system was easy to use. Staff saw incidents as an opportunity to learn and improve.

Lessons had not always been learned from safety incidents or complaints, resulting in changes that improve care for others. For example, when reviewing incidents, we found no evidence of learning from a safety incident following an incident following a discharge from the local acute hospital due to confusion between providers. There was no CCTV on the acquired brain injury wards, therefore there were no cameras to support an incident review to enhance further learning. The provider did not always have enough qualified, skilled and experienced staff to meet the needs of the current patients. The provider had undertaken a benchmarking exercise using a safer staffing tool, which identified that there was a high level of healthcare assistants. Managers told us that they had used the findings to review current staffing levels using the previous year’s use of enhanced observations. However, staffing remained a concern both to patients and staff. Staff were not always able to attend to patients’ immediate needs without taking other patients off observation (or reducing observation levels without an associated risk assessment or requiring additional staff from other wards). The provider’s risk register identifies staffing concerns as a risk, and a review of incidents had not identified a reduction in incidents over time. Managers ensured staff received and were up to date with mandatory training. However, staff did not receive mandatory training specific to the care and treatment of patients who had been subject to a head injury, despite most patients on the ward having had a brain injury. The provider had processes in place which ensured staff received regular supervision. Annual appraisals of work were undertaken for all staff, which included any potential areas of development required. Leaders managed staff with performance issues with assistance from the human resources department.

Patients were not always being nursed under the prescribed levels of observation. Nurses told us that staff had to be taken off patient observations, to attend to patients’ personal hygiene (some patients required 3 staff). These changes to patient observations had not been formally risk assessed, which led to the risk of near misses in terms of incidents and harm. Staff told us that incident reports were completed when patients could not be nursed under the prescribed observation levels). Incident records from 01/01/2024 to 15 July 2024 ward was reviewed. During this time, there had been 59 occasions when observation levels were changed due to staffing levels. A random review of 6 patient incident records February to end July 2024, confirmed that there had been 32 instances where staff had been taken off patient observation, or the level of observations had been reduced (e.g. 1:1 to 15 minutes).

Feedback from stakeholders was positive with regards to safe systems, transitions and pathways. Care and support had been planned and organised with people, together with partners and communities in ways that ensured continuity.

Staff we spoke with described a joined-up approach to care. Patients’ physical health was routinely monitored by the physical healthcare team. Staff made any external referrals to specialist healthcare professionals as and when necessary. Staff ensured that if patients were transferred between wards or from the hospital, appropriate information would be available for the receiving staff.

Patients were supported to understand how to raise concerns when they did not feel safe, or they had concerns about the safety of other people. However, not all patients felt safe and supported to understand and manage any risks. Patients knew who to contact to raise any concerns around safety. Patients were not always appropriately safeguarded when they felt unsafe or experienced abuse or neglect. We were told that a patient had been assaulted down the end of a ward corridor. The area was not staffed, and the provider did not have access to CCTV to review incidents. People were supported to understand their rights, including their human rights, rights under the Mental Capacity Act 2005 and their rights under the Equality Act 2010. Patients told us that wards were not always safe. Three patients told us that they had been assaulted by staff, and 3 patients told us that they had been assaulted by other patients. One patient had been subjected to verbal assaults. However, the provider gave us details of their safeguarding processes; including weekly divisional safeguarding meetings attended by the Local Authority, and the review of safeguarding incidents at daily ward and divisional huddles

Staff understood what safeguarding was and could describe actions they could take to keep people safe. Examples of this included the use of enhanced observations, or for patients to have restricted, or supervised access to items which could potentially cause harm. Any potential or active safeguarding concerns were discussed along with associated risks during shift-to-shift handovers. Staff updated care plans and risk assessments to reflect any new or emerging risks. However, staff told us that wards no longer had access to a safety nurse and how this had led to an increase in patient safety risks and had led to 5 incidents.

There was an understanding of safeguarding and how to take appropriate actions. However, the systems, processes and practices to make sure people were protected from abuse and neglect had not always been effective.

The provider had appropriate policies and procedures in place around the safeguarding of adults and children, risk management and equality and diversity. Managers ensured staff received relevant mandatory training which was up to date. Permanent staff were trained in line with their responsibilities, and in line with national guidance. However, we found 3 instances where staff had not raised safeguarding concerns when referrals should have been made. Staff told us that recent changes to the social work department had left ward staff taking on increased responsibilities around safeguarding, and that they did not have capacity to take on this task. However, the provider told us that this was due to temporary vacancies which have since been recruited into. Staff mostly worked with the local authority as and when needed to maximise patient safety.

The responses we received from people regarding this question was limited. One patient told us that they were unable to access a gym but wasn’t aware why. Staff advised that this had been due to staff availability. One patient told us that they had not seen their plan of care and another patient told us that staff did not include or inform them of any change in care and treatment. However, the provider has submitted evidence which shows involvement of patients in their care.

Staff completed risk assessments for each patient and had reviewed and updated these regularly. Assessment of risk was seen to be a multi-disciplinary approach and were updated at each ward round or when required. Staff only used physical restraint as a last resort if necessary, and for the shortest time possible. There was evidence of restrictive practice. Staff told us that patients do not have immediate access to hot and cold drinks and snacks, and some wards have hourly times for patients to use their vapes.

Staff adhered to the provider policy with reviewing risk assessments at regular intervals, or as and when new risks or behaviours emerged. The provider maintained a restrictive practice log; however, we found several restrictions on the ward including patients being unable to have free access to hot water and snacks and there were restrictions in place regarding patients’ vaping during the day. These restrictions were identified on the wards’ restrictive practice log; however, these were blanket restrictions which were not patient specific or individually care planned.

Most patients (80%) we spoke with felt safe at the hospital, however (20%) 4 patients, told us that they did not feel safe. Two patients stated that there was no point saying anything as there would be no action. Two carers told us that they did not feel that their relative was safe on the ward. Patients did not report any deficits or concerns with the physical environment. All patients had their own bedroom and private bathroom.

Some staff were aware of the ligature risk assessment which senior staff completed annually. Staff had raised concern about the heat in Tallis ward’s dining area and kitchen, and we observed that staff looked uncomfortable due to the heat, which was due to the current hot weather. However, this had been escalated by the ward manager with the estates team and we have since been informed that portable air conditioning units were provided on the ward and in communal areas. Staff told us that the shower room on Church ward had been out of action for a month and that there were no ramps from the communal areas on Church ward to the outside area, despite a number of patients using wheelchairs. However, the provider has informed us that the ward does have a ramp in situ to access all other areas

We noted that ward environments were clean. However, some of the environments look tired and in need of decoration. We noted that the dining room and kitchen on Tallis were uncomfortably hot and there was no air conditioning. The seclusion room on Tavener ward was not safe, as there was a blind spot behind the door. The visitors room on Elgar and Allitsen wards were not welcoming. There was no staff room on Church ward, (however staff have access to a staff room within the same building), and there was no ramp from the dining room, activities room or bedroom corridor to the outside area.

The provider had undertaken ligature risk assessments, which were in date. However, we were not assured that all staff were aware of the identified risks and mitigation, particularly bank and agency staff. There was no system in place to check the understanding of bank and agency staff. The provider told us that as part of their handover the agency and bank colleagues should be given a ward tour and be shown the ligature heat map and audit, however not all agency and blank staff had seen the ligature map. There was a hole in the ceiling of the activities room on Tavener ward (however the provider has told us that estates requests had been submitted for this to be fixed, and there was evidence on the wards action log), and there was a blind spot behind the seclusion room door on Tavener’. The provider had a ward action log, which outlined all the actions required to address environmental issues on the ward. However, staff told us that there were often delays in environmental issues being actioned. The action plan was regularly updated and reviewed.

Eight patients (44%) told us that were not enough staff on the wards and 3 patients spoke to us about staff. Eight patients told us that there were staffing issues on the wards, 3 patients told us that there was a high use of agency, and 8 patients told us that there were often new faces on the ward. One patient told us that ‘this was the problem’ whilst another patient told us that they were not sure of the role of agency staff, and another patient told us that there was a high use of agency staff at night. However, the provider gave us evidence of agency usage sitting at 9% as a total for the division. Six patients told us that their activities or leave had been cancelled or delayed due to staffing levels

Leaders had not always kept staffing numbers at a safe level to facilitate enhanced observations, patients’ section 17 leave, escorts or to enable patients to attend activities. The provider used agency and bank staff when necessary, however not all agency staff were familiar with systems and processes. Staff kept up to date with mandatory training, and any role-specific training or education however agency staff were not dysphagia trained. Staff had effective supervision and annual reviews of their work, and discussions about future learning and development opportunities. Fourteen staff members we spoke with told us that there were not enough staff on the ward on a regular basis, and they had to cross cover from other wards or use bank/agency staff. Staff told us this felt unsafe at times. Between the 6-month period 01/02/2024 and 31/07/2024, the actual WTE (whole time equivalent) staffing was 32,593.09. Of which 57% was permanent planned staffing, 19% was bank, 15% was overtime (which was permanent staff from the hospital doing additional shifts), and 9% was agency (43% not planned). Some staff told us they would like more regular staff, as agency staff continues to be used more frequently, which can put additional pressures on the regular staff due to having to induct them and explain what needs to be completed.

During the onsite assessment, we observed that staff were visible and were in communal areas of the wards. We observed some positive and responsive interactions between staff and patients. However, there were limited staff available for patients who were not being nursed on enhanced observations. Staff were noticeably busy and worked under pressure when enhanced observations were in place or required 2 to 3 staff members to deliver personal care. This resulted in a delay for some patients receiving care. A review of one patient record on 2 August 2024, stated that the patient had been granted escorted leave, and that the patient was to be encouraged to complete twice daily walks within grounds. However, there was no record of any walks being offered or facilitated between 3rd to 13th August as per care plan. Fifteen staff members raised concerns regarding the performance of agency staff. Concerns included lack of training, a lack of performance by agency staff which leads to an increased pressure on permanent staff, and a reluctance of some agency staff to participate in personal care.

There were several vacancies across the division. As of August 2024, there was a total of 14 whole time equivalent registered nurse vacancies (16%) and a 9.5% vacancy rate for unqualified staff. There was a high sickness rate across the division. The highest percentage rate for sickness within the division in July 2024 ranged from 12.15% (on Redwood ward) to zero (on Aspen and Tavener wards). The mean average percentage across the division was 5.5 %, which is lower than the national average Agency, bank staff and overtime were relied on to fill shifts. We reviewed agency, bank and overtime usage for both qualified and unqualified staff from 1 February 2024 to 31 July 2024. During this time there had been a total of 2,200 whole time equivalent of agency staff, 6,138 whole time equivalent usage of bank staff and 4,956 Whole time equivalent usage of overtime. The total whole time equivalent usage for permanent staff was 18, 686. Therefore, the additional staff requirement with overtime was 42% and the additional staff requirement with without overtime was 27%. Managers ensured staff received and were up to date with mandatory and other training. The provider had processes in place which ensured staff received regular supervision. Annual appraisals of work were undertaken for all staff, which included any potential areas of development required. Leaders managed staff with performance issues with assistance from the human resources department.

Patients we spoke with did not express any concerns around infection prevention and control. Patients said the wards were usually clean and tidy.

Staff were aware of and complying with Infection Prevention and Control requirements. All staff were bare below the elbow and were not wearing jewellery or painted nails.

During the onsite assessment we observed there were adequate hand washing facilities and paper towels across the hospital. Hand gel was also available. Staff had available bags for clinical and domestic waste. Staff had access to cleaning materials and chemicals to manage any bodily spillages safely. Bins were available within clinics for any sharps which required disposal. Cleaning records completed fully, and staff had checked and cleaned clinical equipment. However, staff had identified concerns following the mattress audit, which identified concerns with the cleanliness of mattresses. An action plan had been developed to action the recommendations from the audit. Staff were aware of and complying with Infection Prevention and Control requirements. All staff were bare below the elbow and were not wearing jewellery or painted nails.

The provider has an infection prevention and control policy in place which staff could easily access. The provider had a director responsible for infection prevention and control, an infection prevention control group and an infection control link nurse.

Most patients we spoke with did not express any concerns around any prescribed medicines. However, 4 patients told us that they did not know what their medications were for. One patient told us that they were not informed when changes were made to their medications. Patients could discuss any proposed or prescribed medicines with the doctor or nurses during the regular multi-disciplinary meeting.

Staff used an electronic medication management system. Staff had reported medication errors via the incident reporting system. These errors were due to staff not following procedure when dispensing and administering medication on each occasion medication has been given to the wrong patient. Staff received medicine training. Staff told us that regular audits of medicines management were undertaken by senior staff and pharmacy and any actions would be addressed.

Most wards had effective systems and process in place in relation to medication management. However, On Tallis ward, we found that 3 patients had been prescribed prn medication without the associated consent to treatment having been completed. However, this was resolved on the day of our inspection.

The provider had policies and procedures in place which were up to date. The provider promoted use of the 10 R’s Right: patient, consent, time, medicines, dose, route, expiry, documentation, effect and education. However, we found that not all wards had robust systems and processes in place to ensure that patients were only given medication with consent or the appropriate second opinion in place. This was addressed by staff. Medicines were appropriately stored, and staff disposed of medicines in appropriate bins. Staff kept the clinic rooms clean and tidy. Staff monitored patients on high-risk medicines appropriately.