Arbury Court

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We assessed two quality statements from this key question. the rating from the last inspection, was good.
Our rating for this key question is requires improvement.

Staff supervision and appraisal compliance rates were low in the months prior to the assessment.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Assessing needs during this assessment. The score for this quality statement is based on the previous rating for Effective.

Patients felt there was a broad enough range of treatment options available to them. They told us there were activities available such as art and music groups and they shared positive feedback about the groups they had been involved in.

Patients told us they were involved in the development of their care plans. Patients understood what care they were receiving and how they were progressing towards their goals.

Patients told us staff had supported them to understand their prescribed medicines.

Staff told us they met weekly for multi-disciplinary meetings to discuss patients care and treatment. Patients and their relatives were invited to these meetings. Multi-disciplinary teams included consultants, junior doctors and nurses also included psychology, social work input or occupational therapists.

Ward managers were carrying out audits on a range of quality and treatment issues. These audits showed that patients were receiving one to ones from their named nurse.

Staff did not always receive appropriate supervision and appraisals. The provider initially submitted data which indicated that supervision and appraisal compliance rates were 90% and 89% respectively as of July 2024. Following internal concerns in relation to some of the data that was submitted, the organisation provided further data for appraisals and supervision with Arbury Court.

CQC were provided with an overall supervision and appraisal matrix 2024 for Arbury Court alongside individual spreadsheets for the months of March, May, June and July 2024.

The matrix spreadsheet contained significant gaps within the supervision dates recorded in comparison to the monthly spreadsheets. The supervision data has therefore been taken from the monthly spreadsheets only.

We reviewed the appraisal data on the matrix spreadsheet. This matrix recorded 311 staff names. 15 had no appraisal due date recorded. 13 of these 15 had last appraisal dates recorded. 5 of these 13 had appraisals that were done prior to June 2023 so would have been beyond the 12 month review date.

We reviewed the data for the remaining 296 staff. To do this, we analysed the appraisal due date against the first date of the on-site assessment – 22 July 2024. 115 of the 296 appraisal due dates were before the first date of the assessment. This indicated a compliance rate of 61.2%. To note, the matrix indicated that 10 staff were on maternity leave, 2 on long term sick and 2 had left the service.

We also reviewed the appraisal data on the July 2024 monthly spreadsheet. This spreadsheet had 318 staff recorded. 94 of these staff had appraisal due dates that were before the 22 July 2024 (103 before the 31 July). This indicated a compliance rate of 70.4% (67.6% if 31 July).

On the July 2024 monthly spreadsheet there were 321 total permanent staff members listed, with 11 of these being noted as being on either maternity leave or long-term sick. For the 310 permanent staff members listed, 135 had a date recorded for either line management supervision, clinical supervision or both. This meant 43.5% of staff had some form of supervision for a date within July 2024.

On the same spreadsheet, it listed 33 bank staff; all who were identified as clinical staff. 6 of these staff had dates recorded for both line management and clinical supervision in July 2024. A further 6 bank staff had dates for line management supervision in July. This meant 36.4% of bank staff had some form of supervision for a date within July 2024.

On the June 2024 monthly spreadsheet there were 326 total permanent staff members listed, with 11 of these being noted as being on either maternity leave or long-term sick. For the 315 permanent staff members listed, 144 had a date recorded for either line management supervision, clinical supervision or both. This meant 45.7% of staff had some form of supervision for a date within June 2024.

On the same spreadsheet, it listed 107 bank staff; 105 who were identified as clinical staff and 2 were non-clinical. 5 of these staff had dates recorded for line management supervision in June 2024 whilst 2 bank staff had dates for clinical supervision (part-time) in June. This meant 6.5% of bank staff had some form of supervision for a date within June 2024.

On the May 2024 monthly spreadsheet there were 323 total permanent staff members listed, with 10 of these being noted as being on either maternity leave or long-term sick. For the 313 permanent staff members listed, 207 had a date recorded for either line management supervision, clinical supervision or both. This meant 66.1% of staff had some form of supervision for a date within May 2024.

8 staff had incorrect data entry in both the line management and clinical supervision columns which caused an error to show. It was therefore not clear what dates these were intended to indicate.

On the same spreadsheet, it listed 109 bank staff; 107 who were identified as clinical staff and 2 were non-clinical. No bank staff had dates recorded for line management supervision in May 2024. 9 bank staff had dates for clinical supervision (part-time) in May. This meant 8.3% of bank staff had some form of supervision for a date within May 2024.

This data indicated that staff had not always received appropriate supervision and an appraisal in the three months prior to the assessment.

The service had access to a range of specialists to meet the needs of the patients on the ward. Ward staff included, consultant psychiatrists, nurses, healthcare assistants and social workers. Occupational therapists and psychologists were available on request. There were also occupational therapists and activities coordinators. Psychological support was provided in group and individual sessions.


Managers gave each new member of staff a full induction to the service before they started work. Staff received a thorough induction package prior to commencing work. Staff also had a local induction on the ward.

We did not look at How staff, teams and services work together during this assessment. The score for this quality statement is based on the previous rating for Effective.

Medicines safety alerts were reviewed and actioned by staff

Medicines records were completed accurately. When medicines were omitted, staff recorded the reason why.

Medicines used in an emergency were stored safely and checked daily by staff.

Staff followed national policy practice to check patients had the correct medicines when they were admitted or moved between services.

Staff made sure patients had access to physical health care, including specialists as required. We saw that patients had accessed dentists and opticians.

Staff met patient’s dietary needs and assessed those needing specialist care for nutrition and hydration. Patients told us that any religious or dietary needs were met with halal food and vegan diets supported.

Staff had worked with pregnant patients, supporting them through the pregnancy and birth, ensuring that the patients physical and wellbeing needs were met.

Staff identified patient’s physical health needs and recorded them in their care plans. Nurses were using standardised tools to carry out an assessment to understand their physical health needs. All patients had up to date physical health plans. These health screening tools included NEWS2, Malnutrition Screening Tool (MUST), as well as assessments for diabetes, cholesterol and hypertension. Staff ensured dietary needs of patients were met and assessed those needing specialist care for nutrition and hydration. Both wards had equipment and space to undertake physical observations, and electrocardiogram monitoring. Staff followed National Institute for Health and Care Excellence (NICE) guidance when using rapid tranquilisation. From May 2024 when the wards were created there had been seven incidents of rapid tranquilisation. We saw that for one person that had received rapid tranquilisation, records of monitoring of side effects after its use were not always complete as per policy.

We did not look at Monitoring and improving outcomes during this assessment. The score for this quality statement is based on the previous rating for Effective.

We did not look at Consent to care and treatment during this assessment. The score for this quality statement is based on the previous rating for Effective.