- Independent mental health service
St Andrews Healthcare Northampton
We have taken urgent enforcement action by imposing a condition on St Andrew's Healthcare's registration on 14 July 2025 to keep service users safe by restricting new admissions at St Andrew's Healthcare Northampton. We have also imposed a number of conditions on St Andrew's Healthcare registration on 10 November 2025 to require the provider to make improvements in the safety and quality of care provided relating to; staffing, ward environments, blanket restrictions, risk management, observations, incident management, governance and systems and processes.
Report from 21 September 2025 assessment
Contents
Ratings - Services for people with acquired brain injury
Our view of the service
This inspection of services for people with acquired brain injury at St Andrew’s Healthcare Northampton took place in October and November 2025. This inspection was undertaken to follow up on the findings from the inspection carried out in July and August 2025. The wards supporting people with acquired brain injury formed one of the 3 service groups reviewed during this assessment. At the time of the earlier inspection, the CQC had limited the service from accepting new admissions. During this follow-up inspection, we reviewed whether those limits were still justified, whether they remained appropriate to the level of risk, and whether they were still required to protect people from harm.
St Andrew’s Healthcare Northampton is part of St Andrew’s Healthcare, which is a registered charity. The charity provides specialist mental healthcare for patients who may have complex presentations, with challenging mental health needs.
Within the neuropsychiatry division, there were 4 wards for people with acquired brain injury at the time of the inspection. These consisted of; Tavener ward, Allitsen ward, Elgar ward and Tallis ward. The division also had Walton ward, a specialist ward for males living with Huntington’s disease. During this inspection, we focused upon all 5 wards:
- Tallis ward – an admission, assessment and rehabilitation ward for males (11 beds).
- Allitsen ward- an admission, assessment and rehabilitation ward for males (11 beds).
- Tavener ward- an admission, assessment and rehabilitation ward for males (11 beds).
- Elgar ward – an admission, assessment and rehabilitation ward for females (12 beds).
- Walton ward – an admission, assessment and rehabilitation ward for males living with Huntington’s disease (14 beds).
The service was registered to provide treatment of disease, disorder or injury and assessment or medical treatment for persons detained under the Mental Health Act 1983.
At the time of this inspection, the service did not have a registered manager in place.
This assessment service group was last inspected in July and August 2025, when it was rated Requires Improvement.
At this inspection, we reviewed 14 quality statements across 3 key questions: safe, caring and well led. We identified ongoing breaches related to person-centred care (Regulation 9); dignity and respect (Regulation 10); safe care and treatment (Regulation 12); safeguarding (Regulation 13); governance (Regulation 17); and staffing (Regulation 18). As a result of these findings, we rated the service Requires Improvement.
We found significant shortfalls in risk mitigation and safeguarding arrangements. Staff did not consistently protect people from abuse and improper treatment, and individual risks were not always effectively managed or reviewed. Staff did not consistently engage with people during enhanced observations, and some people experienced care that did not fully protect their privacy or dignity, particularly during incidents requiring restraint or transfer across wards. There were repeated incidents of unexplained injuries, prolonged restraint, inconsistent use of de-escalation, and gaps in documentation, including falls assessments and body mapping. Governance systems, audits and incident reviews had not always been effective in identifying, escalating or addressing risks in a timely way, which limited assurance that lessons were learnt and embedded across the service.
However, where possible, patients were supported to have choice and control and were able to give feedback on their care through regular community meetings. The service had undertaken some work to review and reduce blanket restrictions following the previous inspection, including changes to vaping arrangements and individual risk assessments. Patients were supported to maintain relationships that mattered to them through visits, telephone calls and virtual meetings, and some carers described staff as kind and committed to supporting their relatives.
Staff we spoke with were generally positive about working at the hospital and told us they felt supported by their immediate line managers. We met staff who were passionate about improving outcomes for people with acquired brain injury, despite ongoing staffing pressures and reliance on bank staff.
Mental Health Act and Mental Capacity Act Compliance
Most patients on the 5 wards were detained for treatment under the Mental Health Act 1983. Staff stored copies of detention papers and associated records within the electronic patient record, which could be accessed when required.
Staff received mandatory training on the Mental Health Act, with compliance above 90% at the time of inspection.
Staff were able to explain the Mental Health Act Code of Practice and clearly described the guiding principles that informed how they supported and treated people using the service.
Staff had access to advice and support through the provider’s Mental Health Act administration team. The service had clear policies and procedures in place that reflected the relevant legislation and were consistent with the Mental Health Act Code of Practice.
Staff explained patients’ rights under the Mental Health Act and repeated these as required, with records maintained in care notes.
Patients were provided with information leaflets in accessible formats where needed and had access to an Independent Mental Health Advocate (IMHA). Advocacy was provided through the Local Authority, on an individual referral basis.
Mental Capacity Act
Staff received training on the Mental Capacity Act and the five statutory principles. Training on the Mental Capacity Act and Deprivation of Liberty Safeguards formed part of mandatory training, with compliance above 90%.
Capacity to make decisions was monitored and discussed at multidisciplinary team meetings. Where people lacked capacity, staff completed decision-specific capacity assessments and best-interest decisions. However, records did not always show how people and their carers were involved in planning and reviewing their care.
People's experience of this service
During our inspection, we spoke with 10 people using the service. Most people told us they felt safe and spoke positively about staff, describing them as kind and respectful. However, people reported mixed experiences of care. Some said staff treated them well, while others felt this was not consistent.
We observed care across the wards, including during mealtimes and periods of one-to-one observation. Staff engagement varied, and at times staff were present but did not consistently interact with people or provide reassurance, which reduced the benefit of these observations.
We spoke with 12 carers and relatives across wards, and feedback was mixed. Some carers spoke positively about the care provided and the progress their relatives had made. Others raised concerns about communication, unexplained injuries, loss of belongings and delays in physical healthcare. Where concerns had been raised, the provider had investigated and responded, but not all issues had been resolved in a timely way.
Although many people using the service expressed satisfaction with aspects of their care, our inspection found that elements of care did not meet expected standards, particularly in relation to safety, dignity, risk management and governance.