Arbory Residential Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of the legal regulation in relation to safe care and treatment and the way people’s medicines were managed.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

We reviewed records that showed incidents and accidents were reported, investigated and lessons learned shared with staff. Sharing information took place during daily meetings, staff meetings, during handover and via staff messaging. The manager told us they felt confident that staff knew when and how to report incidents and that they had promoted an open culture amongst the staff team where staff felt comfortable doing this. One staff member said, “Yes, we do discuss all the incidents and lessons learned. They’re discussed in staff meetings monthly. It’s to stop them happening again and we do a handover every morning, so we’ll raise any incidents or accidents.”

We saw that onward referrals to external agencies including CQC were made appropriately.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Records showed the service was supported by a multidisciplinary team of healthcare professionals, with established links to local services, including a GP surgery that visited weekly or more frequently as required. This enabled regular health monitoring and medication reviews.

People and their relatives told us they had good access to GP’s and other healthcare professionals, and care plans included appropriate assessments and clinical guidance. Records also showed that people were referred to other professionals for advice and support when needed. Health professionals described the staff as proactive in seeking timely guidance and support. One health professional said, “The staff will make contact when they need our advice or support.”

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

People and their relatives told us they had no concerns about safety at the service. People told us they felt safe and one person’s relative told us, “At home, [it was difficult] but now I can come and visit [name] and I know [name] is safe and cared for.”

Staff had been trained in safeguarding and understood their responsibilities in reporting concerns. One staff member said, “I know what to report. I would report to the management team, if they did nothing I would go to CQC. There are people you can raise concerns to. We have the managers, the regional managers, the Arbory team and the CQC number and email address is in the office.” Staff told us they felt confident raising safeguarding concerns to the management team and knew they would be taken seriously.

There were safeguarding procedures in place. The management team understood their responsibilities regarding any action needed to protect people from harm. We saw necessary internal documentation was completed including accident and incident logs and body maps. The manager ensured referrals and notifications were made to both the local authority and the Care Quality Commission in a timely manner.

People had been assessed for risks such as falls, malnutrition and skin damage. When risks were identified, care plans included information for staff on how to reduce the risk of harm. For example, if people were at risk of skin damage, the care plan included information about any pressure relieving equipment in use and how often people should be supported to change position. However, position change records we looked at did not consistently match care plan guidance. For example, in one person’s care plan, it was documented that the person should be repositioned “4 hourly” during the day and “2-3 hourly” at night, but records over a 3-day period showed an average gap of 4-6 hours. Air mattresses we looked at were set correctly and staff told us the local community team supported with wound care and advice.

Some people were at risk of choking, and care plans included guidance such as any dietary needs and positioning requirements when supporting people with food and drink. The steps staff should take if someone had a choking episode were listed. However, records in relation to the use of thickened fluids were inconsistent and did not always reflect care plan guidance. For example, in one person’s plan it was documented they had been recommended “Level 1 fluids”, but fluid intake records showed staff had documented level 2 and level 0 fluids being provided. Although we saw no adverse impact on people, there was a risk that staff might not be following care plan guidance which might impact on the person’s risk of choking.

Staff we spoke with told us they had access to information about people’s repositioning needs and their dietary requirements.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Safety checks of services such as gas, electric and legionella were in place. At the last inspection, records of checks in relation to fire safety, temperature checks and legionella were highlighted as an area for improvement. At this inspection, records were in place but were not organised or easy to locate. Some gaps were noted. For example, monthly controlled water temperatures were recorded, and we noted some temperatures had been recorded as ‘too hot’ and ‘too cold’ but no corrective actions had been documented on the chart. We were advised that organisation of records was a work in progress.

Although fire drills and fire safety checks were carried out, some fire doors had failed safety checks. This had been identified in January 2026 but not yet been rectified. We discussed this with the facilities and estate manager who went through their action plan with us regarding this. A schedule of nighttime fire drills was also being planned, alongside additional fire training for staff to include the use of evacuation equipment.

Some areas of the environment were tired looking, however there was a refurbishment plan in place, and we saw other areas that had already been refurbished. A newly designated ‘family room’ and new clinical rooms were being put in place, and we saw other areas that had been redecorated.

Cupboards which contained chemicals for cleaning, were not consistently locked. Cupboards beneath sinks in communal areas were also not locked, which meant there was a risk people could access them. We fed this back to the management team who said they would address this. We noted this issue was also identified during the providers quality assurance oversight visit on 21 and 31 April 2026.

On both days of the inspection, the weather was warm. There was signage in place informing staff of the providers warm weather protocol. People’s bedrooms had thermometers in them, but not all of these appeared to be working. We raised this with the manager who told us new thermometers had been ordered. Daily building temperatures had been logged for both buildings, but there was no record of what time of the day the temperature was taken. On a number of occasions, records showed temperatures had reached 25 degrees Celsius. The recording chart advised staff to take action if temperatures fell below 21 degrees Celsius but didn’t recommend any actions if temperatures exceeded a certain temperature. There was nothing recorded to show what, if any, action staff had taken.

At the last inspection, not all gaps in employment records had been reviewed. At this inspection, recruitment procedures had improved, and full employment histories were checked, including any gaps in employment.

Staff had received regular supervisions and told us they felt supported in their roles. Staff said they were provided with training and had access to additional developmental courses if they chose to.

People living at the service gave mixed feedback in relation to staffing levels. Whilst some people told us they felt there were enough staff, others told us, they were aware the staff were busy. People’s relatives told us they did not feel there were enough staff on duty. In particular, they told us they often had to wait some time for staff to be available to either admit them to the building or to access the code for them to leave. For example, one person’s relative said, “Getting access into and out of the home, and between parts of the home, is extremely difficult as it depends on staff availability. It is not uncommon to wait 15 minutes outside. There just don’t seem enough staff around.”

The majority of staff we spoke with also told us they did not feel there were enough of them on duty. Comments included, “We need 3 or 4 staff, but we have 2 at the moment. Sometimes it feels there’s a lot going on and there is an impact. I try to give the best care that I can but when it’s short there’s a lot going on and we can’t do everything we need to do in time, I can’t give good care always.” We observed that on occasions, people were left unsupervised in communal areas and on 2 occasions, we had to step in to reassure people and go looking for staff.

The service used a dependency tool to calculate staffing levels and the rota reflected this. However, feedback from people, their relatives and staff was that overall, their perception was that not enough staff were on duty.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

There were housekeeping staff on duty 7 days per week, and the manager told us the housekeeping team had recently increased to ensure more staff were on duty each day. Although we noted some gaps in cleaning schedules, people, their relatives and health professionals all told us the cleanliness had improved. For example, one person’s relative said, “The home now is spotless. You always see the cleaners working away; they are always on the go, and the toilets are spotless now too. Cleaning standards have definitely improved.”

Staff had been trained in infection prevention and control and knew when to wear personal protective equipment (PPE) and when to change it. We saw staff wearing PPE when supporting people with meals.

In the main, the building was visibly clean and there were no malodours.

During the inspection, the weather was exceptionally warm. Medicine trolleys were stored in a locked room with no ventilation. There was an air conditioning unit in place, but staff told us it was not working. The thermometer in place showed the temperature was 30 degrees Celsius at 12.50 hours. We reviewed records of temperature monitoring over the previous 3 months. On 5 occasions in May, the temperature was recorded as over 25 degrees Celsius. Some of these were recorded at circa 10am and the temperature was recorded once per day. On 26th May, staff had recorded a temperature of 32 degrees but had not recorded on the form any action taken. We saw the high temperature was referred to in a flash meeting on 26th May, but there were no records of flash meetings on previous days when the temperature was also in excess of 25 degrees Celsius. This was not in line with the provider’s medicines policy, and the temperature monitoring process did not show that staff acted on rising temperatures or that high temperatures in excess of 25 degrees Celsius were consistently escalated. The management team took action to address the air conditioning in the medicines room during the inspection. Medicine fridge temperatures were also monitored. However, records did not show that minimum and maximum temperatures had been consistently recorded, which was also not in line with the provider’s policy.

We reviewed topical creams and lotions. None of the creams we looked at had been labelled with an opening date which meant staff would not know if the cream was in date or not. We saw a tube of medicated cream with a dispensing label dated 06/05/25. The instruction label was for the cream to be applied for 7-14 days. Because the tube had not been dated when opened it would be difficult for staff to know if the cream was due to be discarded or if further applications were required. We also saw that medicated creams were stored in people’s bedrooms, and we were told that care staff applied these. We were shown competency assessments for 2 staff members, neither of which had been signed. This was not in line with the provider’s policy.

Patch placement records were not consistently in place. This meant it would be difficult for staff to assure themselves that patches were being rotated in accordance with manufacturer guidance.

Some people were prescribed a thickening agent due to difficulties swallowing. Thickening agent should be kept locked away when not in use because of the risk of aspiration. We observed thickener stored in an unlocked cupboard in a communal area, which meant there was a risk that people could access it. We fed this back to the manager and after the inspection we were told that new lock boxes had been purchased.

We reviewed records of medicines administration and saw that in the main, medicines were administered as prescribed, including medicines that were time sensitive.

Although medicine audits had been carried out and areas for improvement identified, including the areas we noted, improvements had not been consistently put in place.