All inspections: St Andrew's Healthcare - Mens Service

This unannounced focused inspection was triggered by the receipt of information which gave us concerns about the safety and quality of services on two wards at the hospital. CQC received this information of concern between July and September 2022. Our last inspection of this service was in June 2022.

The concerns received included the following:

safe staffing levels and how incidents were safely managed
physical healthcare and care of the deteriorating patient
one incident of poor medicine management
use of restrictive practices.

Our rating of this location stayed the same. We rated it as requires improvement because:

We found:

On Heygate ward, the night shift lacked leadership to support staff to make decisions on how to minimise restrictive practice and maintain effective relational security.
On Heygate ward, there was a delay in prescribing medication to one patient. Referrals to the physical healthcare team for out of hours admission were not always robust.
On Heygate ward, night staff implemented a blanket restriction without clear rationale.
Despite remedial action taken by the provider there was a strong smell of drains from the toilets in the therapy corridor of Malcom Arnold House, leading to Heygate ward.
We found 4 incidents of staff sleeping on duty on Fairbairn ward.

However:

Both wards showed that while nursing shifts had not started with the planned number of staff, managers filled gaps with known bank staff to bring staffing levels up to safe numbers. Staff told us that in the previous few months staffing levels had improved. The provider had improved pay and conditions for staff and had measures in place to address both recruitment and retention of staff. We found the staffing issue had improved at our last inspection of these services in June 2022, and there was evidence of slow but continued improvement since our last inspection.
All staff we spoke with knew how to report incidents and record them in the electronic system. We reviewed incident records against safeguarding referrals and daily care notes which confirmed this judgement. Managers shared lessons learned from incidents within teams to prevent future occurrence of the same incident.
Compliance with safeguarding training was 100% on Fairbairn ward and 80% on Heygate ward. All staff we spoke with understood what constituted a safeguarding concern.
Staffing levels meant enhanced observations had been carried out safely.
Staff managed the routine physical healthcare of patients well and managed physical healthcare incidents well.

Our rating of this location improved. We rated it as requires improvement because:

Not all ward areas in all services were clean safe or well maintained. In three of the four services inspected we identified worn furniture, dirty ward areas or broken fixtures and fittings.
Staff did not always ensure medicines management was safe in two of the four services inspected. We found some medicines were out of date, gaps in some audits of controlled medicines and clinic checks.
In one service, enhanced observations were not always completed in line with the providers’ policy and guidelines by the National Institute for Health and Care Excellence. We found an occasion when staff undertook patient observations for long periods of time without a break.
Blanket restrictions remained in place in one service despite having reduced most restrictions. In forensic inpatient or secure wards, patients did not have access to hot and cold drinks and had set times for vapes and no access to mobile phones.
Staff were not up to date with mandatory training in three of the four services inspected. This meant not all staff had the skills and competence to carry out their role.
Seclusion records we reviewed were of poor quality and did not meet the Mental Health Act Code of Practice. None of the patients were offered the support of an Independent Mental Health Advocate (IMHA). Independent Multidisciplinary Team (MDT) reviews were not clearly recorded.
Bank staff in one service were not trained in approved de-escalation and restraint techniques to ensure patients were not exposed to unnecessary risks of harm and abuse.
Staff did not always develop person centred care plans that reflected patient’s involvement or views. Care plans were not always in place for all the needs of those who used services. Staff did not always offer patients copies of their care plans.
In one service, staff did not always meet the hydration needs of people to ensure a patients’ fluid intake was adequate.
Managers had not ensured that all staff had received annual appraisal and regular supervision in two services.
Staff access to specialist training was not always possible as staffing wards in a safe way took priority.
We witnessed one occasion in one service where staff used language that did not promote the dignity or respect one person who used the service.
Systems and processes were not always effective enough to identify issues and gaps in service delivery.

However:

Oversight of staffing had improved, and managers had ensured staffing numbers were flexible and generally able to meet patients’ needs. Staff and patients were reporting a much-improved picture since our last inspection. This meant we saw an improvement in how enhanced observations were met. The correct staffing was in place and recording of enhanced observations had improved.
Staff managed patient risk well. The provider had made strides to reduce restrictive practices across most services in collaboration with patients in restrictive practice groups. Staff had the skills required to develop and implement good positive behaviour support plans to enable them to work with people who displayed behaviours of concern.
Incident reporting had improved, and we saw evidence of lessons learned following incidents were effectively shared across services.
Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided. Change leader workshops had been provided to ensure staff had the right skills to be able to evaluate clinical practice.
The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards.
Staff treated people with compassion and kindness. Staff attitudes had improved since our last inspection and the provider had completed work within a culture change project. Patients were positive about their experiences, and we saw this reflected in the results of the ‘My Voice’ survey about quality of care.
Staff actively involved people, families and carers in care decisions.
Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
We were pleased to hear that a permanent post was now in place for a lead Freedom to Speak up Guardian and we heard the vision to develop further the awareness for staff on the role and how to speak up.
Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients.
Staff planned and managed discharge well and liaised with services that provided aftercare. As a result, discharge was rarely delayed for other than a clinical reason.
We were able to see the effects of the work the provider had delivered on change in culture. The work that the provider was doing included workshops, training, regular bulletins for staff and leadership behaviours to role model a positive culture. Services had carried out significant work on improving the culture on the wards, had visible local and senior leadership and had improved governance systems to monitor service delivery. Staff told us they were proud to work for their services and had seen a positive shift in culture.

Our rating of this location stayed the same. We rated it as requires improvement because:

Following our inspection we took urgent action because of immediate concerns we had about the safety of patients on the learning disability and autism wards. Conditions were placed on the provider's registration that included the following requirements; that the provider must not admit any new patients without permission from the CQC; that wards must be staffed with the required numbers of suitably skilled staff to meet patients’ needs; that staff undertaking patient observations must do so in line with the provider’s policy; that staff must receive required training for their role and that audits of incident reporting are completed. The provider is required to provide CQC with an update relating to these issues on a fortnightly basis.

Whilst the CQC acknowledge the impact of the COVID-19 pandemic on staffing across the health and social care sector, we had identified staffing issues at this location at our previous inspection. Our assessment process for rating services requires previous breaches to be considered.

Senior managers and staff on the learning disability and autism wards did not always treat patients with compassion and kindness and did not always support, inform and involve families or carers. Staff at the learning disability and autism wards were unable to define a closed culture or describe how they ensured patients were protected from the risks associated with a closed culture developing. Staff on the learning disability wards and forensic wards did not always treat patients in seclusion with dignity and respect.
The psychiatric intensive care ward, forensic wards and learning disability and autism wards did not always have enough nursing and support staff to keep patients safe and the wards were regularly short staffed. Patients regularly had their escorted leave, therapies or activities cancelled or cut short because of staff shortages.
Staff did not manage risks to patients and themselves well. Staff did not always follow the provider’s policy and procedures on the use of enhanced support when observing patients assessed as being at higher risk harm to themselves or others. This happened on the psychiatric intensive care ward, forensic wards and learning disability and autism wards. Staff did not always know what incidents to report and how to report them at the forensic wards, long stay rehabilitation wards and learning disability and autism wards. Staff were not always updating patient risk assessments and care plans at the forensic wards, long stay rehabilitation wards and learning disability and autism wards. Staff did not always ensure patients’ physical healthcare needs were met at the forensic wards and learning disability and autism wards. Staff were not always following systems and processes when administering, recording and storing medicines on the learning disability and autism wards. Not all ward areas at the long stay rehabilitation service and learning disability and autism service were safe, clean and well maintained.
Seclusion rooms did not meet all the guidance in the Mental Health Act Code of Practice on the forensic wards, long stay rehabilitation wards and learning disability and autism wards. When a patient was placed in seclusion, staff did not always follow best practice guidelines on the forensic wards and learning disability and autism wards. When a patient was placed in long term segregation, staff on the forensic wards and learning disability and autism wards did not always follow best practice guidelines in the Mental Health Act Code of Practice.
Managers did not ensure all staff had the right skills, qualifications and experience to meet the needs of the patients in their care on the forensic wards and learning disability and autism wards. Staff did not always provide a range of care and treatment suitable for the patients in the long stay rehabilitation wards and learning disability and autism wards. The service had not fully responded to the needs of patients with autism at the learning disability and autism service.
Leadership and governance arrangements across all core services had not addressed previous issues or ensured concerns were identified and acted on. The provider’s data was not always accurate. Not all leaders had a good understanding of the services they managed. Not all staff felt respected, supported and valued by senior managers. Not all staff felt they could raise concerns without fear of retribution from senior managers. Senior managers are managers above ward manager level.

However:

Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
Staff liaised well with services that would provide aftercare and were assertive in managing care pathways for patients who were making the transition to another service. As a result, discharge was rarely delayed for other than clinical reasons.
The provider had a care awards initiative to celebrate success and improve the quality of care across services. Staff engaged in local and national quality improvement activities. The provider reported involvement in various research projects.

We did not rate this service.

We carried out this inspection in response to concerning information received through our monitoring processes.

We found the following areas the provider needs to improve:

Managers had not ensured safe and clean environments. The ward was dirty, cluttered, poorly maintained and in need of redecoration. Staff did not always follow infection control principles. Managers had not ensured the review of ligature assessments in line with the provider’s policy. We observed a patient using an area on their own, that managers assessed as requiring staff supervision to mitigate against identified ligature risks. However, on a return visit the provider had deep cleaned and de-cluttered the ward.
Patients did not have direct access to outside space. Whilst the ward had a garden area allocated, this was located away from the ward and was not easily accessible. Facilities did not meet patient needs; disabled facilities were not easily accessible.
Leaders and governance arrangements did not assure the delivery of high quality care. Leaders had been planning to move the ward to more suitable premises for over a year. Senior managers had not ensured that the ward environment was safe and clean and were focused on moving the ward at the expense of ensuring the quality of the ward environment was acceptable. We were concerned that the provider had been aware of these issues for a significant period of time and the ward continued to be an unpleasant environment for patients and staff. There was no clear model of service, the provider described the service as ‘locked rehab’, the service was registered as a ward for older people with mental health problems and senior managers told us the service provided ‘specialised nursing’.

However, we found the following areas of good practice:

The provider had made improvements to fire safety and medicines management following the last inspection and Mental Health Act review visit.
The provider had agreed actions to improve the environment of the ward and completed a deep clean and de-clutter and stopped using the laundry room as a kitchen between our visits.

We rated Men’s services as requires improvement because:

Seclusion practices were not compliant with the Mental Health Act code of practice. Medical and nursing reviews had not taken place as required in 36% of records checked. Staff had not completed seclusion care plans for patients in 70% of records checked.
Doctors advised that they were not always able to complete seclusion reviews within the timescales required by the Mental Health Act code of practice. We reviewed data for weekend on call provision, which evidenced that the demands on doctors providing this support exceeded available on call medical staffing.
Managers had not identified all environmental risks in patient areas on forensic, learning disabilities and older adult’s wards. We found unidentified ligature risks and blind spots.
The provider had not ensured that all risk assessments and care plans were in place and updated consistently in line with changes to patients’ needs or risks.
The provider had not ensured that patients’ physical healthcare needs were met in accordance with care plans. There was no out of hours physical healthcare provision on site.
Managers had not ensured that all patients requiring observation had appropriate care plans.
Staff had not created personal emergency evacuation plans for patients with restricted mobility on the older adult’s wards. Staff had limited access to specialist equipment for moving patients with restricted mobility down stairs in the event of a fire.
Staff had not followed safe procedures for the recording of medicines administration on one forensic ward.
We found issues with cleanliness and maintenance on the forensic and learning disabilities wards.
The provider had not ensured all medical equipment was regularly tested to check it was in working order. On upper Harlestone ward, we found staff had not regularly tested the oximeter and blood pressure machine.
The decor and furnishings on Foster ward were poor.
There were insufficient numbers of staff to provide safe care, treatment and access to leave and activities on the forensic, older adults and learning disabilities wards.
There was a lack of consistent management on Foster and Harlestone wards.
The provider had implemented changes to staff roles without fully assessing the impact and had not communicated the changes effectively.

However:

Staff treated patients with kindness, compassion and respect. We observed interactions between staff and patients during the inspection and saw that staff were responsive to patient's needs.
Staff were open and transparent and would explain to patients and carers when things went wrong.
Staff knew what constituted a safeguarding, and could explain the process of reporting and escalation to senior staff. Staff put protection plans in place for patients when required.
Staff had access to appropriate alarms and radios to call for help in the event of an emergency.
Staff reported incidents in line with policy. Senior staff cascaded information about lessons learnt to staff at ward level.
Staff were aware of the provider’s whistleblowing policy and were confident they could raise concerns without fear of reprisals. Staff spoke positively about the support received from managers.
Ward managers were able to adjust staffing levels to meet the changing needs of patients requiring high levels of monitoring linked to individual patient risks.
Wards had fully equipped clinic rooms with access to resuscitation equipment, which was regularly checked and maintained.
Staff had a good knowledge of the Mental Health Act and Mental Capacity Act.
Wards had a variety of rooms for patients to use including quiet, therapy, fitness and activity rooms.
Staff had good access to training and received the necessary specialist training for their roles.
The provider held regular governance meetings to monitor the service. Managers used key performance indicators to monitor their wards performance.

We did not rate this service.

We carried out this inspection to check compliance following the warning notice issued after the focused inspection in May 2017.

We found the following areas the provider needs to improve:

Seclusion records reviewed did not always include sufficient recording to demonstrate that all of the safeguards under the Mental Health Act code of practice had been met. Medical and nursing staff had not always completed reviews in line with the Mental Health Act Code of Practice. Staff had not always fully completed seclusion documentation.
Managers were not supervising staff in line with the providers management supervision policy introduced in November 2017. Data provided by the service as of the 30 November 2017, evidenced a management supervision compliance rate of 20% overall for forensic and rehabilitation wards. Three wards reported compliance rates of 0%.

We found the following areas of good practice:

Managers and staff ensured that wards were clean, maintained and well furnished.
Staff had completed risk assessments for all patients and full physical health assessments for 95% of patients on admission. Patient records had evidence of ongoing physical health care.
The provider had addressed the issue of staff being trained in two types of restraint technique. At the time of our visit, 91% of staff in the men’s service had completed Management of Actual and Potential Aggression training.
Staff demonstrated a good understanding of safeguarding practices. The provider reported that 94% of staff had completed level 1 and 2 safeguarding training. Staff were able to describe action they would take if they had safeguarding concerns.
Governance and monitoring processes had improved. The service director and clinical director chaired weekly governance meetings with consultants, ward managers, multi-disciplinary leads, modern matron and compliance manager.

We rated St Andrew’s men’s services as inadequate because:

The provider had not addressed the issues identified in the June 2016 inspection whereby staff were trained in two types of managing aggression and restraint. It was still the case that staff were trained in two different types of managing aggression and restraint. This posed a risk to staff and patients if staff were following two different approaches. In the May 2017 inspection we identified the following concerns.
Some of the wards were not clean or safe. Ferguson ward was dirty and had plaster falling off the walls. This posed an infection control risk. The standards of cleanliness were poor on three wards and the issue had not been identified through the provider’s own monitoring system. In addition, the provider’s ligature audits had not identified how to mitigate risks posed by potential ligature anchor points. This problem was compounded by the fact that staff did not always update the risk assessments of individual patients following an incident.
Staffing levels were poor in most clinical areas. Although staff establishment numbers were met at the beginning of a shift, they were not increased when more staff were needed to undertake patient observations or because staff were required to help out on other wards. Staff shortages meant that patient activities and leave were sometimes cancelled. Also, shifts often had one qualified member of nursing staff, especially at night, which meant that staff could not take breaks. Agency nurses employed to make up the shortfall did not all have access to the electronic prescribing system to administer medicines. This meant that a member of staff from another ward had to come to assist.
There was a high turnover of staff indicating staff retention as a problem. Turnover was 32% in one forensic ward, 22% in the psychiatric intensive care unit, and 20% on a rehabilitation ward.
The standard of record keeping was poor in forensic and rehabilitation services. We identified that retrospective entries had been made in a seclusion record. We brought this to the attention of a manager. Handovers in forensic and rehabilitation services were poor. There was no structure, pieces of paper were used to write on and patients were not discussed in handover until the inspection team pointed this out. Records did not always document discussion around a patient’s capacity. Record entries in the learning disabilities service were sometimes punitive in nature. Records of ongoing physical healthcare monitoring were poor in all but older people’s and learning disabilities services. Risk assessments did not identify all risk factors.
The long term segregation policy did not meet the Mental Health Act code of practice in respect of review requirements. For example, the long term segregation policy allowed for the nurse in charge, rather than an approved clinician, to review the patient daily, and allowed for another division of the hospital (rather than an external hospital) to undertake the three monthly reviews. We found that staff were confused about what constituted seclusion and long term segregation. Many staff described patients as being in ‘extra care’ when in fact they were either secluded or in long term segregation.
A theme from discussions with all staff groups, including medical, nursing, social workers, and psychology staff, was that admissions were not always clinically led. We were given examples of when a clinician’s decision had been overridden by non clinicians. This posed a risk of inappropriate admissions.
From information given to us on inspection, both in groups and individually, we formed the view there was an oppressive culture in these services. Different staff groups, including nursing staff, medical staff, psychologists, and social workers, reported a fear of speaking up in case of reprisals.

However:

In older adults there was effective provision of physical healthcare. Staff had received specific training to carry out their role, such as dementia training and end of life care. Staff received regular supervision and appraisals.
The provider had taken action to address the shortage of staff. It had run many recruitment fairs in an attempt to attract staff to work at St Andrew’s and staff were being recruited. The Aspire programme enabled healthcare assistants to become qualified nurses with a bursary provided by St Andrew’s Healthcare.
There was an emphasis on positive behaviour support planning and a continued move to reduce the use of restraint, including prone restraint. The use of restraint was monitored by the restrictive practice monitoring group which met monthly to review the use of restraint in all services. Data showed a downward trend in the use of restraint, with the provider reporting a reduction in restraint by 32%, and a reduction in the use of prone restraint by 38%. According to the provider, the use of seclusion had decreased by 17%. Staff in learning disabilities completed detailed positive behavioural support plans with patients that included triggers and ways in which staff and patients could reduce negative behaviours.
Patients knew how to make a complaint and there were effective systems in place to support managers to investigate complaints and identify an outcome.
Staff supported patients with physical health issues. Staff completed annual healthcare assessments with patients and supported access to specialist services, where required.
There were weekly manager and matron meetings to review issues, monthly quality and safety meetings which included the managers, clinicians, and compliance manager. There were weekly bed management meetings to review bed numbers.
At the time of the inspection, a new leadership team for the service had just been put in place who were actively addressing the concerns within the service. The recently appointed service director had identified and understood the improvements which were required in the men’s pathway. They had introduced a local audit two weeks before the inspection and piloted on one ward. The aim of this was to have more immediate action taken when issues were identified.

We did not rate this service.

We found:

The provider had strengthened the implementation of positive behaviour support (PBS) planning since the last inspection in June 2016.
Staff we spoke with were knowledgeable about using least restrictive practices for restraint and positive behaviour support planning, a recommended approach to managing patients challenging behaviour.
Staff were caring and keen to do their best for the patients. They were respectful in their approach.
Care plans and data supported what staff had told us about the use of restraint as a last resort and only after staff had tried to de-escalate and divert patients who were becoming distressed or agitated.
Data provided showed a downward trajectory in the use of restraint and in the use of prone restraint.

We also found:

The electronic system was difficult to navigate to find key documents such as positive behaviour support plans. Staff saved some documents on a shared drive rather than in the electronic system. Staff we spoke with knew where to find the information they required, however, information was not consistently in the same place for each record.
The behaviour observations sheets used codes for behaviour and it was not always clear which exact behaviour related to which code. This meant staff may not be clear what behaviour was expected in certain situations.
Some seclusion records were missing and staff could not find them.
Medical staff raised an issue about completing medical reviews for seclusion at night with only one doctor on duty for the site, and a second doctor available until midnight.

We rated St Andrew’s Healthcare Northampton as requires improvement because:

Not all seclusion rooms considered the privacy and dignity of patients. Staff used closed circuit television (CCTV) to monitor patients. However, monitors were visible to staff from the office and to patients on entering or leaving the adjacent low stimulus room. In adolescent services, one seclusion room had a faulty two-way intercom system. Care records confirmed that the room was used regularly and recently. In older adults services the provider did not always reduce the risk from blind spots.

In forensic services, the receptionist controlled access to three buildings from one reception area and used CCTV monitors to control access. When reception staff were away from their desk, access to the building was delayed for patients.
On Seacole ward there were issues with controlling temperatures on the ward. This was because of the air exchange system sending columns of cold air directly downwards when the ward gets above 28 degrees. The provider told us they were going to fit a safe diffuser over all of the ducts to try to diffuse the cool air over a larger area. On Seacole ward, the furniture in the night lounge was torn and dirty. In the psychiatric intensive care unit (PICU) some bedrooms, bathroom and shower areas were dirty and carpets were not clean. We could detect a strong smell of urine in some bedrooms. The shower areas upstairs did not provide comfort or promote dignity and privacy. There was a shower curtain on some, but not all showers. The door to the room did not lock and patients needing the toilet could enter. We observed staff searching patients in communal areas on two wards. One ward lacked appropriate signage and other relevant information for patients with neuro rehabilitation needs. Staff restricted access to patients wishing to use their bedrooms, and this was not individually risk assessed.
There were ligature points in the psychiatric intensive care unit and the provider did not ensure all patients’ risk assessments and care plans included the management of specific environmental ligature risks. There was no recorded evidence of staff and patients having an immediate debrief following an incident. A debrief is an opportunity for staff to reflect on the incident, review what action was taken, any immediate lessons learned and to offer support to patients and staff.
The provider had high vacancy rates in forensic, neuropsychiatry, older adults and rehabilitation services. This was particularly high for registered nurses. The provider used bureau (St Andrew’s bank staff) and agency staff to fill vacant shifts. However, a significant number of shifts remained unfilled. Staff told us when shifts were not filled, staff moved between wards to meet patient need or wards worked short of staff. Staffing levels at night were particularly low.
In rehabilitation, adolescent and forensic services, staff did not always complete physical healthcare monitoring following administration of rapid tranquilisation or commencement of seclusion. Staff did not always complete physical healthcare monitoring for patients prescribed specific medications and staff did not complete the relevant chart regularly or appropriately. Staff in forensic services did not always document fully what patients had been offered or received. There were gaps in records where staff had not signed the entries. In rehabilitation services, staff did not always respond appropriately to a decline in a patient’s physical health and did not use observation tools to review and assess the response needed.
Not all staff had completed training in the Mental Health Act (MHA) or the Mental Capacity Act (MCA). Staff did not receive annual MHA training and the provider could not demonstrate that staff had received training in the revised MHA code of practice. This meant that staff were not working to the most recent guidelines. Staff did not read patients their rights under section 132 of the Mental Health Act in some wards. If patients did not understand their rights, staff did not always make further attempts. On PICU, forensic, rehabilitation and older adult’s wards staff had not uploaded the MHA legal detention papers in full to the electronic system. Some records had part of the paperwork uploaded.
In some services staff did not assess patient’s capacity to consent to treatment appropriately. Staff documented patients did not have capacity but did not give a rationale as to why they had made this decision nor document any discussion. Mental capacity assessments were not decision specific. Consultants did not always accurately complete medication consent paperwork (T2 and T3 forms). Staff kept some information in paper format.
The provider did not have an effective management supervision structure. Supervision was highlighted as an issue in learning disabilities, older adults and rehabilitation services. Supervisions occurred monthly by peers rather than line managers in some areas. We saw that some staff had different supervisors each month. This meant there was no consistency and managers could not be sure that supervisors were addressing performance issues.
Not all groups of staff felt engaged with the developments and changes to the service.

However:

There had been improvements since the last inspection. Leadership had been strengthened and new ways of working implemented to improve the patient experience. The provider had improved governance systems and carried out recruitment drives to attract staff. There had been an overall decline in the use of agency staff over the preceding 12 months.
Most wards were safe, visibly clean, homely and well furnished. Patients could access garden areas and open spaces. Patients held their own mobile phones wherever possible and had private access to a landline telephone that had direct lines to advocacy and other services. Wards had a range of rooms for care and treatment and rooms for patients to meet visitors in private. Wards had seclusion rooms, low stimulus rooms and extra care suites for patient use. Patients could personalise their bedrooms and had lockable spaces to secure possessions. The provider had procedures for children visiting. Staff provided a range of activities for patients and activities were available seven days a week.
On most wards, staff updated patients’ risk assessments regularly and included patients’ individual needs. Staff in forensic services completed regular ligature risk assessments and wards contained very few ligature risks. Staff managed known risks with nursing observations and individual risk assessments. Staff had quick access to ligature cutters and pocket masks (for use in mouth to mouth resuscitation) in different areas of the wards. Staff used positive behavioural support plans with patients effectively.
Staff undertook comprehensive assessments and developed care plans that were thorough, holistic and patient centred. With the exception of rehabilitation, adolescent and forensic services, staff monitored the physical health of patients regularly and developed physical health goals and treatment for patients. Staff used outcome measures such as health of the nation outcome scale and specific tools for acquired brain injury patients. Physical healthcare services included dentistry and podiatry. Practice nurses from the GP surgery attended the wards to address patients’ physical healthcare needs. Staff made prompt referrals for any further specialist physical healthcare input.
Staff were passionate about their job and knew patients well. Patients told us staff worked hard and were kind to them. Most staff treated patients with dignity and respect and were responsive to patients’ individual needs.
We saw leadership at ward manager level. Managers said they felt supported and staff said they felt valued. Senior staff monitored incidents and discussed outcomes in team meetings. Some senior staff gave examples of learning from incidents for their ward. Staff told us morale was increasing following a period of change over the last two years and told us their managers were supportive. Multidisciplinary teams worked effectively across all wards.
The provider had ongoing recruitment and retention programmes to attract new staff. Staff received training in safeguarding and made appropriate referrals. There was a range of psychological interventions available for patients which patients were encouraged to attend. Staff trained in British sign language (BSL) were available to patients on Fairbairn ward. The provider had an induction programme for new staff and was supportive of further learning opportunities for all permanent staff. Staff received annual appraisals and most staff received regular supervision. Staff attended regular team meetings and recorded any actions and outcomes from these.
In some wards, Mental Health Act 1983 (MHA) paperwork was in order and stored securely. MHA administrators had a thorough scrutiny process. Some staff used the Mental Capacity Act to assess capacity for individual decisions. There were appropriate systems for managing and recording complaints. Patients had access to independent advocacy services. This meant that they were able to receive independent support to help them express their views and assist with any appeal against their detention under the MHA if they so wished.
Managers had access to dashboards for their teams, which gave details of staff compliance with mandatory training. Nurse managers reported they received prompts from the provider’s training department when staff’s mandatory training or refreshers were due.
The provider managed quality and safety using a variety of tools. There was a dashboard for monitoring ward performance, quality and safety against agreed targets. There was a monthly lessons learnt bulletin for staff. Staff told us they knew the whistleblowing policy and felt they could raise concerns without fear of victimisation. Managers were visible on the wards and staff felt supported by operational managers and clinical nurse leads.
The managers told us, and we saw the documents to show, they were offering an ‘Aspire campaign’, which supported healthcare support workers to undertake their nurse training. The provider would pay these staff a bursary to support their training, following which they would return to work at St Andrew’s for a minimum of two further years. The provider had plans to support 20 staff a year in this scheme.

We found ligature risk and environment audits were undertaken every six months We saw that some ligature risks had been identified and there were contingency plans in place to manage these.
The clinic rooms were fully equipped and resuscitation equipment was checked regularly and recorded however not all wards had equipment. There were a number of locked doors, stairs and potentially an unpredictable patient group, which may impact how quickly the equipment arrived where it was needed.
Not all wards had a seclusion facility available for use. Grafton and Hereward Wake wards did not have a seclusion room. On Hereward Wake, this meant that a patient requiring seclusion was being transported to a different location by secure transport. We heard on rare occasions the transport was unavailable leaving both the staff and patient at risk.
We were told that some agency staff and some bureau staff did not have access to the electronic notes system meaning that patient information would not be readily available in an emergency. Patients told us that due to high levels of bank and agency staff who did not know them caused them to be cared for and treated differently.
Patients told us that the CAMHS service were insufficiently staffed which meant that they were not always able to have their granted leave. Managers agreed that at times it was difficult to ensure the safety of the ward, whilst meeting the needs of the patients.
Some staff and patients told us that they did not feel safe on the learning disability wards
We saw rotas which showed the wards were regularly using bank or agency staff, Mackaness had three members or regular staff on duty and six agency staff on the day of our visit.
Fairbairn Ward management informed us the electronic system did not allow them to specify staff trained in British Sign Language. This meant patients were not always able to communicate effectively with staff to make their needs known.
Staff received training in de-escalation skills and conflict resolution
We found that in the CAMHS service prone restraint was still being used when retraining young people. We also found that risk assessments and Care plans around this restraint were not always in place.
We found that routine restrictive practices were in place to manage risk, behaviours related to daily care and treatments were measured using generic levels.
On the learning disability ward some staff did not know the safeguarding process or where they could find out about current ward issues.
Some staff did not demonstrate understanding about appropriate use of seclusion facilities in the learning disability services.
On Seacole Ward, there were errors in the recording of medication administration
Sitwell ward was not consistently documenting patients review of restraint
Sitwell ward was not following St Andrew’s Seclusion policy with regard seclusion reviews with patients.
Staff throughout the organisation were aware of how to report incidents and we saw good examples of staff learning from the investigation of adverse events
We found that the CQC had not been sent notifications relating to incidents affecting the service or the people who use it within the learning disability service.
We found in the older adults services that care plans were detailed, personalised and accurate to the care we observed being provided
We found in the learning disability service some care plans were generic and not person centred, in particular the risk safety system.
Staff working in the neuropsychiatry services had an understanding of current NICE guidelines.
The neuropsychiatry services used positive behavioural therapy for the rehabilitation of patients with acquired brain injury.
Nursing and support staff we spoke with in the CAMHS services did not have any understanding of positive behaviour support.
There did not appear to be an opportunity for patients to appeal against decisions made about their risk levels, or clear individual behaviour markers and goals for changes in levels.
Learning disability patients told us that the restrictions around the risk safety system made them angry.
We found that the risk based safety system is being used to manage non risk behaviours such as non-engagement.
We were told that there were issues around maintaining staff on Fairburn ward who were trained in British sign language (BSL). It often occurred that staff were trained up to a level to work with patients, then moved to work on other wards.
Appraisal of performance was undertaken annually.
Staff stated that that the training offered by St Andrew’s was excellent.
During our visit, we witnessed several occasions where staff responded to patient’s distress and they did so discreetly and appeared to be always mindful of the patient’s dignity.
In the learning disability services there was not a clear and effective system for comprehensive handovers between nursing staff due to the set nursing shifts.
We found on Tavener ward that informal patients were asked to sign a contract for granted leave, which does not reflect the Mental Health Act.
Patients on the PICU did not have access to a lockable space in their bedrooms and they did not always have their room key.
We saw patient’s views were included in care plans and this included relatives where appropriate.
Community meetings were held weekly services where patients could raise issues related to the ward, minutes were available for us to view.
There was little evidence that patients or their carers were actively involved in writing or reviewing their care plans on the learning disability wards. Most patients did not have a copy of their care plan or knew what their goals were. Those that did have care plans on Bradlaugh found that it was not in accessible format.
We looked at the Mental Health Act paperwork for patients and found it to be accurate and complete in all sections.
Staff were trained in the Mental Capacity Act and the Deprivation of Liberties Safeguards (DoLS).
Wards had examples of restrictive practices such as kitchens being locked and reliant on staff for hot drinks on Berkley close. On Althorp ward sweets were not allowed and the times for hot drinks were restricted.
Blanket restrictions were also seen on the CAMHS units, for example on one ward young people were prevented from having sugar and there were restrictions around the length and time of day that young people could make telephone calls.
Independent advocacy services were available to all patients.
A relative we spoke with told us the team on the ward liaised well with her relative’s professional team in their home area to ensure the care was effective and were accurately informed of their progress.
There remain issues around mixed gender accommodation on some older adults wards.
Patients told us that they felt the wards could be cleaner and the furniture in places was damaged and not replaced.
There had been an increase in the group of patients with Huntingdon’s disease on Tallis ward which affected the clinical risks on the ward and this was raised as a concern, this was being addressed by staff receiving extra training in this area.
We found that the CAMHS service had a number of “extra care” beds, these were generally patients segregated from the main ward area and cared for in isolation. The policy around such practice was ambiguous and this was confirmed by the records we viewed.
Each ward had a book dedicated to learning from incidents and complaints generated across the hospital site. This ensured learning not just from their own ward but from other services. We saw action plans arising from complaints and the resultant changes on the wards.
We found that the space on the older adults wards was a challenge to make feel homely, however we saw they had utilised the ends of corridors to create small areas of interest
Learning disability wards were part of the overall deregation project and were not suitable to meet patient’s needs, for example they were not accessible for patients with significant physical disabilities or requiring wheelchair access.
In the learning disability services significant blanket restrictions were seen for example cigarette breaks were taken hourly, drinks were at set times, access to bedrooms were restricted and no access to kitchens or sensory rooms unless accompanied by an occupational therapist.
Some staff in the learning disability services told us that there was little engagement with senior managers or the organisations values and they did not feel able to engage with the wider organisational systems.
The ward managers in the older adult’s service told us they felt supported in their roles and had excellent support from the directors of the service.
The PICU hospital director offered regular open clinical between 7pm and 9pm which were open for staff to attend.
There were recognised difficulties in the learning disability services in ensuring that the wards had the correct staff skill mix for the patient’s needs. There were regularly high numbers of bank and agency staff used across these wards.
We saw that staff in the neuropsychiatry services and PICU were using tablet computers to monitor outcome measures electronically while on the ward which meant that they saved time by not returning to the desktop computer and logging into the electronic note system.
The PICU ward was affiliated to the National Association of Psychiatric Intensive Care and Low Secure Units (NAPICU). This is an organisation which is involved in promoting and developing work within the PICU settings.
Hawkins and Makeness wards had recently participated in the overall William Wake House “self” and “peer review” parts of the quality network assessment for forensic mental health services.

The purpose of the follow up visit was to check whether the provider had made improvements to areas found non-compliant during our last visit in August 2013.

We also looked at seclusion facilities and seclusion records, as concerns had been identified at a Care Quality Commission Mental Health Act seclusion monitoring visit on 22 November 2013.

The inspection team consisted of one CQC compliance inspector and a mental health specialist advisor. We visited Bradlaugh, Ferguson and Fairbairn wards. We spoke with staff, patients and the ward managers.

We found the provider had made improvements to the d'cor on Bradlaugh ward, although the replacement of the worn chairs on the ward was still outstanding.

We also found that improvements were needed to meet full compliance with the regulations in relation to the use of seclusion.

We visited Cranford, Rose, Grafton and Bradlaugh wards, which provided treatment and support for males with mental health needs, acquired brain injury and learning disability. Within medium and low secure and locked ward environments.

We spoke with 22 people who used the service and asked them about their experience of using the service. Quotes received from people are included throughout the report.

We saw that each ward had a team of staff involved in people's care and treatment, which included psychiatrists, psychologists, nurses, occupational therapists, qualified mental health nurses and health care assistants. This meant that arrangements were in place to ensure people were supported by appropriately qualified and skilled staff.

We saw that St Andrew's Healthcare had an on-going staff recruitment programme and on the first day of our visit we saw that staff interviews were taking place. The main area of dissatisfaction from the majority of people we spoke with was about restrictions to activities and outings brought about through having limited staff resources on the wards.

We found that people were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines.

We visited Harlestone ward which is a low secure ward situated over two floors (Lower Harlestone and Upper Harlestone) and is part of St Andrew's Healthcare Men's Service.

We spoke with seven patients and they all expressed satisfaction with the care and treatment they received at the hospital. They told us that the staff treated them with respect. We found that each patient had a daily schedule of therapeutic activities. We saw that records were kept of when patients had engaged in scheduled activities and also when patients had declined to carry out their activity. Patients told us that they had access to escorted leave. One person said sometimes their escorted leave had been cancelled due to staff shortages. The staff confirmed that leave had been cancelled on some occasions, due to staff shortages, but was not a regular occurrence. During our visit we saw that six patients from Upper Harleston ward were out on escorted leave to Milton Keynes shopping centre to do some Christmas shopping.

Patients told us they had opportunities to use the on site gym, but were dissatisfied with the limited space within the secure courtyard facility. An example was given as there not being enough space to run and kick a football.

We visited two wards within the Men's service: Foster low secure ward that provides forensic treatment for men and Ferguson a low secure ward that provides rehabilitation and recovery. We interviewed seven detained patients and asked questions in relation to their care.

Patients said they had a 'good rapport' with staff, and confirmed there were good links with the advocacy service. They said there was good access to the medical team and opportunities to discuss their ongoing care and treatment with the psychologists' at St Andrew's Healthcare.

All of the patients we spoke with told us they participated in one to one and group activities. These included using the on site gym and swimming facilities, going on bike rides, playing squash and badminton, and shopping. Some patients spoke of taking part in an allotment and music group. Some people spoke of attending social events held within St Andrew's grounds and some said that they enjoy their escorted visits into town.

One person said 'St Andrew's has a lot to offer; they are helping me to move on'.

Each year, we visit all NHS trusts and independent providers who care for people whose rights are restricted under the Mental Health Act to monitor the care they provide and check that patients' rights are met. Immediate concerns raised by patients on those visits are discussed, if appropriate, with hospital staff.

Our Mental Health Act Commissioners may carry out a number of visits to each provider over a 12-month period, during which they talk to detained patients, staff and managers about how services are provided. In the past, we summarised themes from the visits and published an annual statement followed by the provider's response where applicable. We are looking at different ways to indicate the outcomes of our monitoring in the future.

These older reports are from our old approaches to inspection, including those from before CQC was created.

Archived: St Andrew's Healthcare - Mens Service

All Inspections

18 October 2022

During an inspection looking at part of the service

14 to 16 June 2022; 28 to 29 June 2022

During a routine inspection

5-8, 20-21, 29 July 2021 and 3-5 August 2021

During a routine inspection

17 and 24 July 2019

During an inspection looking at part of the service

26 to 29 March 2018

During a routine inspection

9-10 and 16 January 2018

During an inspection looking at part of the service

15 to 19 May and 1 June 2017

During an inspection looking at part of the service

7,8,10 February 2017

During an inspection looking at part of the service

13 - 16 June 2016

During a routine inspection

9 -12 September 2014

During a routine inspection

16, 17 January 2014

During an inspection looking at part of the service

1, 2 August 2013

During a routine inspection

13 December 2012

During a routine inspection

17 August 2011

During a routine inspection

Mental Health Act Commissioner reports

Reports under our old system of regulation