The Care Quality Commission
  • Mental Health
  • Independent mental health service

Archived: St Andrew's Healthcare - Womens Service

Overall: Requires improvement read more about inspection ratings

Billing Road, Northampton, Northamptonshire, NN1 5DG (01604) 616000

Provided and run by:
St Andrew's Healthcare

Important: We are carrying out a review of quality at St Andrew's Healthcare - Womens Service. We will publish a report when our review is complete. Find out more about our inspection reports.

All Inspections

5 6 11 27 28 29 April 3 4 May 2022

During a routine inspection

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

  • Across all services, the provider was challenged to ensure staffing numbers met the needs of patients and we found in some cases, patient activities had been cancelled or postponed. There was a high use of regular bank staff and agency staff.
  • Staff had not always followed the provider’s policy on patient observations in two services. We found gaps in observation records.
  • Therapy provision on wards for people with a learning disability was below establishment and affected the delivery of therapeutic activity. One of the long stay or rehabilitation wards, which supported patients with secondary needs associated with disordered eating, did not have access to a specialist dietician.
  • Staff did not always ensure that the privacy and dignity of all patients was respected and maintained. Staff did not always demonstrate the values of the organisation when supporting patients.
  • Environments on wards for people with a learning disability or autism wards were not always maintained due to untimely responses to complete repairs and manage estates issues.
  • One seclusion room did not have a shower and whilst the provider had made progress in the processes to plan, fund and source a shower in the seclusion room, it remained without a shower.
  • Two services did not make timely repairs to the environment when issues were raised.
  • In two services, care plans did not always reflect how to manage patients with physical health issues. Staff on long stay or rehabilitation wards staff did not ensure patients had a care plan in place for the use of rapid tranquilisation. Staff on forensic inpatient or secure wards did not always undertake and record physical health observations following rapid tranquilisation.
  • Blanket restrictions continued to be in place on most wards. In wards for people with a learning disability or autism, seclusion occurred in areas other than a seclusion room and staff did not always record it correctly in line with the MHA Code of practice. Staff on forensic inpatient or secure wards reported a high number of incidents that required restraint and staff did not undertake searches in line with the provider’s policy.
  • Not all staff in wards for people with a learning disability or autism knew how to find patient information on the electronic record.
  • We found staff did not always safely manage medicines and act on audit results on three services we inspected.
  • In three services, governance processes in place did not always ensure checks and audits were effective enough to ensure care delivery was improved. For example, gaps in environmental checks, long term segregation reviews, and medicines management checks were not followed up.

However:

  • The provider had recently implemented a new system for calculating the right numbers of staff required, based on the acuity of patient need. This was enhanced with a bleep holder system which reviewed the real time staffing situation in addition to the electronic system. This meant senior staff could move staff to where need indicated it was higher on some wards. There were meeting three times in a 24-hour period to review staffing across all wards.
  • When restrictive practices were used, there was a reporting system in place and there were comprehensive reviews to try and reduce the use of these practices. We noted ward teams had made improvements to reducing restrictive practice since our last inspection.
  • The provider as part of a national pilot, had developed a new clinical model (co-produced with staff and patients), which was a blended approach including low and medium security.
  • Managers ensured that staff had relevant mandatory and specialist training, regular supervision and appraisal. Managers dealt effectively with poor practice and the provider had made significant improvement in following policy and procedure to deal with outcomes of investigations.
  • People and those important to them, including advocates, were actively involved in planning their care. Multidisciplinary teams worked well together to provide the planned care.
  • Staff understood their roles and responsibilities under the Human Rights Act 1998, Equality Act 2010, Mental Health Act 1983 and the Mental Capacity Act 2005.
  • Staff worked well with services and external organisations that provided aftercare to ensure people received the right care and support when they went home.

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

During an inspection looking at part of the service

Letter from the Chief Inspector of Hospitals

This service was placed in special measures on 10 June 2020. Insufficient improvements have been made such that there remains a rating of inadequate for any core service, key question or overall. Therefore, we are taking action in line
with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.
The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within six months, and if there is not enough improvement we will move to close
the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.


Professor Edward Baker
Chief Inspector of Hospitals

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

Following our inspection we took urgent action because of immediate concerns we had about the safety of patients on the forensic, long stay rehabilitation and 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.

  • Staff on the forensic, long stay rehabilitation and learning disability and autism wards did not always treat patients with compassion and kindness. Staff did not always respect patients’ privacy and dignity on the forensic and long stay rehabilitation wards. 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.
  • The service did not have enough nursing and support staff to keep patients safe at all core services. Patients regularly had their escorted leave, therapies or activities cancelled 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 at all core services. Staff on long stay rehabilitation wards did not always know what incidents to report and how to report them, however staff in the other services we inspected did know what to report and how. Staff did not always follow the Mental Health Act code of practice in relation to seclusion, long term segregation, blanket restrictions and section 17 leave on the long stay rehabilitation and learning disability and autism wards. Staff were not always updating patient risk assessments and care plans at the psychiatric intensive care and long stay rehabilitation wards. Staff did not always ensure patients’ physical healthcare needs were met at the psychiatric intensive care, forensic and long stay rehabilitation wards. Not all ward areas at the long stay rehabilitation service and learning disability and autism service were safe, clean and well maintained. Staff on the forensic wards did not always follow infection control procedures.
  • 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. The provider had not fully responded to the needs of patients on the long stay rehabilitation and learning disability and autism wards.
  • The leadership, governance and culture did not always support the delivery of high quality, person centred-care. Leaders at the long stay rehabilitation services did not have the skills, knowledge and experience to perform their roles. Concerns identified at previous inspections had not always been addressed.
  • Staff did not always feel respected, supported and valued on the long stay rehabilitation and learning disability and autism wards. Managers did not always support staff with appraisals, supervision and opportunities to update and further develop their skills on the forensic and long stay rehabilitation wards.

However:

  • Each patient had their own en suite bedroom, which they could personalise.
  • Leadership development opportunities were available.
  • Staff received and kept up to date with training on the Mental Health Act and the Mental Health Capacity Act.

08,13,14, 22 and 24 July 2020

During an inspection looking at part of the service

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 did not ensure staff had the right skills, knowledge and experience to meet the needs of patients with a diagnosed eating disorder. Staff had not completed full assessments for patients with a diagnosed eating disorder prior to admission. Staff had not completed care plans that met all the needs of patients with a diagnosed eating disorder. Staff did not provide a range of care and treatment options suitable for this patient group.
  • Staff did not manage patient risks effectively. Staff did not always complete observations in line with patient care plans and the provider’s policy and procedures. Staff did not complete care plans for all identified risks. Staff had not met all patients’ physical health needs.
  • Managers did not provide a safe environment for patients. The ward was not resourced with equipment required to support patients with an eating disorder. A patient was in a distressed state for over an hour due to lack of specialist equipment. Staff did not follow correct infection control procedures in relation to coronavirus. We observed staff not wearing personal protective equipment (face masks) appropriately when on the ward.
  • Staff did not always treat patients with kindness, dignity and respect. We observed a senior member of staff dismiss a patient who asked to speak with them about safeguarding concerns. We spoke with a senior member of staff who described patients with an eating disorder as “not a patient group who inspires excitement”. Patients described occasions when they were distressed and staff ignored them.
  • Staff did not always identify and report safeguarding concerns. Managers had not notified CQC about seven out of eight safeguarding incidents and had not referred one to the local authority safeguarding team.
  • Carers reported issues with communication and gave examples of having to ‘battle’ to be listened to and be involved. Patients and carers reported that managers were dismissive of concerns raised.
  • Patients told us that there was not enough food, catering staff did not send meals or sent the wrong meals, food was sometimes "mouldy" and was not always cooked properly. Patients told us there were limited food options, especially if vegetarian. This was raised on numerous occasions in community meetings with no evidence of any action taken. However, we reviewed evidence that staff checked quality and temperature before serving food.
  • Managers had not effectively managed the change to the ward profile. Managers continued with the planned change despite training not being available, due to coronavirus restrictions, and the ward not being sufficiently resourced. Managers had not followed recommendations from an internal investigation into concerns raised.

However:

  • Senior leaders demonstrated learning by acknowledging that a lesson learnt was to ensure new services have the correct capabilities in place prior to opening and reported that they were making changes following concerns being raised.
  • Staff completed annual physical health assessments for all patients and completed standard physical health checks. We saw evidence in progress notes that staff sought support from the provider’s physical health team when required.
  • Staff supported one patient sensitively on the anniversary of a traumatic life event.
  • Patients described the new dietician as ‘amazing’.
  • Two carers told us that the social worker was helpful and another two told us their relative was in the right place for the care and treatment they needed.

24 February 2020, 02-06 March 2020 and 13 March 2020.

During a routine inspection

Following our inspection, we issued a letter of intent informing the provider we were considering taking urgent action because of the immediate concerns we had about the safety of patients. We told the provider they must provide immediate assurance in relation to staffing levels, staff completing enhanced observations of patients in line with National Institute of Health and Care Excellence guidance and staff reporting incidents and appropriate action is being taken. We received the requested assurance.

We rated St Andrew’s Healthcare Women’s service as inadequate because:

  • Safety was not a sufficient priority across the service. Staff did not always keep patients safe from avoidable harm whilst on enhanced observations on the forensic wards and on the psychiatric intensive care unit. Staff did not always follow the provider’s policy and procedures on all wards on the use of enhanced support when observing patients assessed as being at higher risk harm to themselves or others. Patients alleged that staff on Sunley ward used inappropriate restraint techniques. Levels of restraint significantly increased since the last comprehensive inspection across the forensic service. Staff did not always record details of restraint techniques used.
  • There were times when patients were not well supported and cared for. Staff did not always treat patients with kindness, dignity and respect. Staff at the forensic service used derogatory and inappropriate language to describe patients. Staff at the forensic and learning disability services misgendered patients. Staff at the long stay rehabilitation service did not always uphold patients’ dignity in relation to medication and care.
  • Managers had not ensured established optimum staffing levels on all shifts. The provider reported that 12% of shifts were unfilled between 01 February 2019 and 31 January 2020. The provider reported 13 forensic service failure incidents due to staff shortages between 01 September 2019 and 29 February 2020. Patients and staff told us that staff shortages often resulted in staff cancelling escorted leave, hospital appointments and activities across all cores services.
  • We were concerned that staff were not reporting all safeguarding concerns to the local authority safeguarding team at the forensic and psychiatric intensive care services. Staff at these services were not reporting all incidents and not recording all incidents appropriately. Staff did not always follow the Mental Health Act Code of Practice in relation to seclusion, long term segregation and blanket restrictions. Staff were confused about what constituted long term segregation and the purpose of using long term segregation.
  • Managers did not ensure safe and clean environments in the long stay rehabilitation service and learning disability service. Staff did not learn from cleanliness audits. Staff had not completed the Elgar ward ligature risk assessment. Facilities and premises used on Elgar and Spring Hill wards were not appropriate for the service being provided. Staff failed to maintain reliable systems, processes and practice around medicine management. We found issues with inappropriate storage of medicines, staff not labelling opened medications, patient allergy information and a significant medication error.
  • Patients were at risk of not receiving effective care and treatment. Staff did not always support patients’ physical health needs effectively at the long stay rehabilitation and forensic services. We reviewed incidents where staff had not provided physical health interventions as required and staff did not always record patient’s physical health or nutritional needs.
  • Staff did not always share clear information about patients and any changes in their care. Staff in the forensic service did not always complete handovers in line with the provider’s policy and procedures. We found examples of poor record keeping of handovers. Staff arrived late to handovers. Staff were not completing risk assessments on Elgar ward, with information being copied between records for different patients.
  • Managers did not ensure all staff received appraisal and supervision at the forensic and learning disability services. Managers on the learning disability wards and forensic wards did not make sure staff received specialist training for their role.
  • The leadership and governance did not always support the delivery of high quality, person centred-care. The providers governance processes had not addressed staff failures to follow the provider’s procedures. Leaders did not always understand the issues, priorities and challenges the forensic and long stay rehabilitation services faced. We were not assured that leaders had taken sufficient action to address concerns raised during the focused inspection of the forensic service in January and February 2020 or addressed concerns of the same themes identified at other service inspections in St Andrews Healthcare.

However:

  • Staff provided a range of care and treatment interventions suitable for the patient group. The teams included or had access to the full range of specialists required to meet the needs of patients on the ward. Teams held regular and effective multidisciplinary meetings.
  • Staff supported patients to engage with the wider community. There was a chaplaincy service and access to spiritual leaders for other faiths.
  • Senior leaders were visible across the location and were approachable for patients and staff. Staff told us that the chief executive officer visited regularly. Occupational health services and a trauma nurse supported staff physical and emotional health needs. The provider invested in a programme of support to promote staff well-being.

24 January 2020 and 05 February 2020

During an inspection looking at part of the service

We did not rate this service.

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

Following our inspection, we served an urgent Notice of Decision because of the immediate concerns we had about the safety of patients. We told the provider they must not admit any new patients until further notice; that wards must be staffed with the required numbers of suitably skilled staff to meet patients’ needs and to undertake patients’ observations as prescribed; that staff undertaking patient observations must do so in line with the provider’s engagement and observation policy and protocol and the provider must ensure there is clear documentation to inform staff of the current observation level of all patients. We told the provider that they must provide CQC with an update relating to these issues on a fortnightly basis.

We found the following areas the provider needs to improve:

  • Patients were at risk of continuing harm. Staff did not always act to prevent or reduce risks to patients and staff. Staff did not always keep patients safe from harm whilst on enhanced observations. Nine out of fourteen self harm incidents reviewed occurred due to staff not completing enhanced observations as prescribed.
  • Staff did not always follow the provider’s policy and procedures on the use of enhanced observations when supporting patients assessed as being at higher risk of harm to themselves or others. We found gaps in hourly observation records on 193 out of a possible 1,008 occasions. We found that shift leads allocated staff to complete enhanced observations for the same patient for up to twelve hours and allocated staff to complete observations continually throughout a shift for different patients for up to ten hours. This is not in line with the providers policy and does not adhere to guidelines by the National Institute for Health and Care Excellence (NG10). Staff completing extended periods of enhanced observations may be less likely to maintain the levels of concentration required to maintain patient safety.
  • The service did not have enough nursing and support staff to keep patients safe. We reviewed 26 incidents that occurred between 1 November 2019 and 3 February 2020. Of these, 13 incidents related to a lack of suitable or sufficient staff impacting on patients’ care. Examples included patients not attending hospital for required emergency medical interventions due to lack of suitable staff to support.
  • The provider’s board had not authorised the use of mechanical restraint, in line with guidance, and staff had not followed care plans in relation to the reporting and monitoring of mechanical restraint.
  • The leadership, governance and culture did not always support the delivery of high quality, person centred-care. The providers governance processes had not addressed staff failures to follow the provider’s procedures on enhanced observations, handovers and safety checks. There was no evidence that the provider undertook regular and effective audits of these issues.
  • Staff spoken with were burnt out and distressed. Staff told us that they dreaded coming into work and felt professionally vulnerable.
  • Senior managers told us the concerns that triggered the focused inspection were not a surprise and that Seacole was on their watchlist. This was concerning as staff told us they had been raising concerns since August 2019 and there was still a high occurrence of self harm incidents on our first day of inspection.

However:

  • On our second visit we were assured that senior leaders had started to address the concerns and were providing the ward with the support needed. The provider reported that the frequency of incidents had reduced following our inspection visits.
  • The provider had recently changed the local leadership of the ward. The new ward manager and operational lead had recently started in their posts. Staff and patients spoke highly of the new manager and we observed that positive changes had been made on our second visit.
  • Managers had recently recruited a new senior nurse and staff were returning from long term sick leave. The ward manager told us that they had block booked agency staff for the next six weeks, to improve consistency in care and they were booking more staff than required.
  • The provider recently introduced daily ‘safety huddles’ involving the whole staff team. Staff discussed current concerns and risk issues for all patients and agreed on actions required.

24- 25 July 2018

During an inspection looking at part of the service

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 did not ensure established staffing levels on all shifts. The provider reported that 1,698 shifts out of 15,788 were unfilled for the period 1 February 2018 to 30 June 2018. This equated to a fill rate of 89% against the provider target of 90%. There were not always enough staff to safely carry out physical interventions and provide the required level of patient observations on Sunley ward. We reviewed seven incident reports. Staffing levels at the time of the incidents were recorded in each report. Staffing was below the establishment number for five incidents reviewed.
  • The provider was not compliant with the Mental Health Act Code of Practice. We reviewed 22 out of 115 seclusion records from 1 April 2018 to 30 June 2018. Doctors and nurses did not complete records for all of the reviews as required by the Mental Health Act code of practice. Staff had not completed seclusion and long-term segregation care plans for all patients. The multi-disciplinary team had not conducted reviews as required. Sunley and Bayley ward seclusion rooms had blind spots in the ensuite areas, although the provider reported these immediately. Staff did not always provide patients with information about their rights under the Mental Health Act.
  • Managers had not ensured a safe environment at the learning disabilities service. Whilst managers and the health and safety lead had completed ligature audits for Spencer North and Sitwell wards within the last six months prior to inspection, there was no hard copy of the ligature audit and assessment available. Staff on Spencer North did not know where to find the ligature audit. Staff had not received the necessary specialist training for their roles on Sunley ward. There had been an incident one weekend where there were no nasogastric trained staff available to administer the nasogastric feeds to a patient requiring this intervention.
  • Staff had not followed the dysphagia care plan for one patient on Sitwell ward, which had resulted in a choking incident. Staff administered backslaps and dislodged the food.
  • Managers did not share learning from incidents with their teams in the forensic and learning disabilities services. We reviewed ten team meeting minutes from January 2018 and weekly memos from 1 June 2018 sent by managers to staff and there was evidence of one incident being discussed in one meeting. The provider told us they shared learning from incidents via alerts sent by email. However, staff told us that they would hear of incidents on other wards by word of mouth rather than through any formal means.
  • Staff did not always follow National Institute for Health and Care Excellence guidance for the use of rapid tranquillisation on Sunley ward. Staff told us that rapid tranquillisation medication was administered most days. We reviewed one patient’s records who had been administered rapid tranquillisation medication twice in one day. Staff had not completed the required physical health checks following both administrations.
  • There were blanket restrictions on Sunley ward. Staff told us patients’ snack times on the ward were 11am and 4pm. Staff did not allow patients to have snacks outside these times.

However, we found the following areas of good practice:

  • Staff told us that they received de briefs and support after serious incidents. This included visits from senior managers, support from the provider’s trauma manager and free access to a confidential helpline. We reviewed minutes from a de brief session, which confirmed this.
  • Managers had implemented additional safety measures following serious incidents, these included updating the ligature audit and assessment following a ligature incident, ensuring staff with specific training were available to provide specialist support to patients and a review of patients’ access to contraband items.
  • Staff ensured most patient’s needs were assessed and met within care plans. We reviewed 21 care and treatment records for patients. Staff had completed person centred and holistic care plans for 20 patients reviewed. Staff had completed physical health assessments for patients on admission accessed specialist healthcare providers when needed.
  • Patients had good access to physical healthcare when needed. A physical healthcare team, based on site, were available during the week to offer support with patients’ physical healthcare needs. Staff could access emergency physical health care from the provider’s emergency response teams and the local general hospital to cover out of hours emergencies.

15 to 19 May and 1 June 2017

During an inspection looking at part of the service

We rated St Andrew’s as good because:

  • Care plans were comprehensive and holistic, and contained a full range of patients’ needs. Staff completed patients risk assessments in a timely manner and updated these after incidents.
  • Wards had adequate space for delivering care and treatment of patients, with appropriate seclusion rooms, low stimulus rooms, and extra care suites for patient use. All patient bedrooms had ensuite facilities.
  • Managers ensured that staff had received training in safeguarding and made appropriate referrals.
  • A range of psychological therapies recommended by the national institute for health and care excellence was available for patients.
  • Patients had access to independent mental health advocacy.
  • St. Andrews Hospital had its own physical healthcare team who saw patients on the wards.
  • Staff cared for patients who presented with behaviour that challenged. Managers and staff worked extra shifts to support the wards, which showed resilience and commitment toward delivering patient care.
  • Wards had family friendly visiting rooms along with policies and procedures for children visiting.
  • Staff received regular supervision and had received annual appraisal.
  • Senior staff monitored incidents and discussed outcomes and learning from them in team meetings.
  • There were robust systems in place for reporting and investigating incidents and complaints. 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.

However:

  • Staffing numbers did not meet establishment levels. There were high numbers of vacant posts. Whilst managers booked agency staff to cover vacancies at short notice this resulted in staff who were often unknown and unfamiliar with the wards and the patients. In particular high numbers of registered agency nurses had been booked for night duty, many of whom were male, and not known to the female patients. Agency staff did not have access to all of the systems, adding additional responsibilities onto the permanent staff.
  • The provider had not addressed the issue identified in the June 2016 inspection whereby staff were trained in two types of managing aggression and restraint. Fifty one percent of staff had received Management of Actual and Potential Aggression (MAPA) training and 47% of staff were trained in Prevention and Management of Aggression and Violence (PMAV). The remaining staff (2%) were out of date with training. This posed a risk to staff and patients if staff were following two different approaches.
  • Staff were unclear about the definitions and terminology relating to de-escalation, restraint, seclusion, segregation and extra care. Policies for seclusion, long term segregation and enhanced support were confusing and the long term segregation policy did not meet the Mental Health Act code of practice in respect of review requirements. Staff did not fully complete seclusion records, including physical healthcare monitoring during an episode of seclusion.
  • There was insufficient medical cover for overnight on call and emergencies.
  • Managers and medical staff told us that in recent months they had felt pressurised into accepting patients, who in their clinical opinion, were not suitable. Medical staff told us clinical decisions were made at a senior level without any evidence based rationale or consultation at a clinical level.
  • Feedback from focus groups and information received through CQC also reported a bullying culture in some parts of the organisation. However, the provider does have various avenues through which staff can raise grievances and concerns. There were no formally reported cases of bullying or harassment when we visited the service.
  • Seacole ward had outstanding maintenance issues. The heating was not working properly. We had identified a similar issue in the June 2016 inspection. Staff and patients reported a smell of sewerage in the ensuite bathrooms of some rooms. Sunley ward was not clean, bed linen was stained and smelly, and dirty linen was stored with clean linen.

7,8,10 February 2017

During an inspection looking at part of the service

We did not rate this service.

We found:

  • The provider had strengthened the implementation of positive behaviour support planning since the last inspection in June 2016.
  • All staff we spoke with in learning disabilities services followed positive behaviour planning (PBS) and least restrictive practices. They were knowledgeable about the principles of PBS and were involved in observing behaviour and reporting to the multidisciplinary team to enable planning. PBS care plans were available in paper form for staff to have easy access and in easy read for patients when needed, as well as on the electronic system.
  • Staff were caring and keen to do the best for the patients. They were respectful in their approach.
  • Staff told us and plans showed that restraint was used as a last resort and staff tried to de-escalate and divert patients who were becoming distressed or agitated. Prone restraint was used only when the patient had requested it in their care planning (some patients prefer to the floor forward instead of backward), the patient had put themselves on in that position or if an injection was required. The patient was turned onto their side or back as soon as possible and the majority of prone restraints lasted less than three minutes. The training department staff supported and trained staff to use other sites for injecting medication to reduce the need for any prone restraint to give medication.
  • Data provided showed a downward trajectory in the use of restraint and in the use of prone restraint. Staff reported incidents accurately and in line with the provider’s policy.
  • Staff received mandatory and specialist training and most were up to date.

We also found:

  • The electronic system was difficult to navigate to find key documents such as PBS reports and some plans. Some documents were saved on a shared drive rather than in the electronic system. Staff we spoke with knew where information was, 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 the exact behaviour to which the code referred. This meant staff may not be clear what behaviour was expected in certain situation.
  • 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.

13 to 16 June 2016

During a routine inspection

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.

9 -12 September 2014

During a routine inspection

  • 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.

9, 10 January 2014

During an inspection looking at part of the service

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 July 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 Spring Hill House, Sitwell and Stowe wards. We spoke with staff and people using the service and the ward managers for the three wards visited.

We found that the provider had taken account of our previous inspection findings and had introduced additional quality monitoring measures.

However, we did find that improvements were needed to meet full compliance with the regulations in relation to the use of seclusion.

4 July 2013

During a routine inspection

We visited Spring Hill House, a treatment and recovery unit for women with borderline personality disorders. On the day of our visit the provider informed us there were 21 people residing at Spring Hill House. We spoke with eight people who used the service and six staff.

In response to a compliance action issued following our last inspection in November 2012 the provider was able to demonstrate that necessary maintenance works had taken place to the wards heating and cooling systems to ensure they were in working order.

In response to a compliance action issued following our last inspection in November 2012, the provider demonstrated they were actively recruiting staff. However people using the service and staff spoke of their frustrations when staff were taken off Spring Hill House to work on other wards within the Women's Service. They told us this affected the quality of the service they received and restricted their engagement in planned therapeutic activities. This meant that due to staff redeployment to work on other wards the arrangements in place to ensure people were supported by appropriately qualified and skilled staff were not being effectively managed.

19 November 2012

During a routine inspection

We visited Thornton Ward and Spring Hill House within St Andrew's Healthcare Women's Service, Northampton. The patients we spoke with told us they liked the staff and were satisfied with the standard of care they received.

We found that each patient had a daily schedule of therapeutic activities. During our visit we saw some patients engaged in their daily activities, such as participating in current affairs sessions and playing board games with other patients and staff. We were told that ward community meetings took place and we saw records of the meetings were kept. One patient told us they really enjoyed being involved in the community meetings and looked forward to them.

Some patients told us they were concerned that sometimes their planned activities, such as outings in the community had been cancelled due to low staffing levels at Spring Hill House.

At both Thornton Ward and Spring Hill House the patients had expressed concerns about the heating not being suitable, for example bedrooms and communal rooms being either too hot or too cold. At Spring Hill House, we saw that refurbishments were taking place to the shower and bathing facilities.

21 November 2011

During a themed inspection looking at Learning Disability Services

We spoke to the majority of patients throughout our two day visit. All of the people that we spoke with were able to verbally communicate with us.

We received mixed comments from the patients that we spoke with over our two day visit. In total we spoke with ten patients. The majority of patients felt they were supported well by the staff team on the ward. One patient said,' 'yes the staff are good here they are always ready to have a chat with you'. Another patient told us 'they try to give you a healthy diet and we do a lot of exercise groups'.

Some people were not happy about being on the ward because they were detained their under the Mental Health Act 1983. Although this was done to keep them and other people safe it meant that there were restrictions on what they were able to do and where they were able to go.

Two patients told us that their families did not live locally and they were not happy because their families were unable to visit on a regular basis.

Mental Health Act Commissioner reports

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.