Arbury Court

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

We assessed six quality statements in the safe key question and found it to be requires improvement. The provider had previously been inspected and safe was rated as requires improvement.
The provider had not maintained the premises and equipment which was a breach of regulation. They had failed to maintain the environment on Clover ward with mould in an ensuite and fixtures and fittings which required replacing. Black mould is a type of fungus the spores of which can be harmful and can cause people to develop respiratory issues. Black mould should be removed as quickly and safely as possible and steps should be taken to prevent it from growing back.
Some observation sheets had not recorded those observations had taken place on two patients.

Staff mandatory training compliance was below 75% for some of the training courses, including therapeutic observations and engagement, which was a concern as patients that we spoke to described that staff undertaking enhanced observations did not often engage or interact with them.

There were effective systems and processes to protect people from abuse and neglect. Staff understood how to protect patients from abuse. Staff completed risk assessments for patients.
There was sufficient staff to support patients with a full multi-disciplinary team in support.

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 Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

Staff on both wards could tell us about the patients and discussed why they are doing observations and the risks presented by the patients.
Staff told us that thorough handovers and debriefs took place to ensure information was shared about the patients. Handovers were recorded and we saw they covered all the patient’s activity that day, incidents that had occurred and changes to care implemented due to those incidents.

We saw that partners were consulted on all care decisions and attended regular meeting to discuss the care of the patients.

We looked at daily briefing sheets and observation records. Each ward used an observation booklet which contained information about each patient and recorded other information such as a patient’s fluid or food intake. There was also a section for staff to record observations about the patient which was handwritten but included information about the patient’s demeanour and what activity they were undertaking. Although staff demonstrated they were aware of processes we found evidence they failed to follow the process they described. On two of observation records on Clover we found that staff had not completed these observations in the required period for each individual patient.

Patients reported feeling safe on the wards and that they felt that they could raise any concerns with staff or managers. They were aware of how to raise a complaint and described that they felt confident in doing so. Patients who had experienced aggression or restraint, told us they felt staff had dealt with them professionally and appropriately.

Staff told us they received training on how to recognise and report abuse, appropriate for their role and kept up to date with their safeguarding training.

Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act.



Staff followed clear procedures to keep children visiting the ward safe. A specific visiting room was available to book for visits with children which was separate from the ward.

Staff knew how to make a safeguarding referral and who to inform if they had concerns. Staff told us they felt confident to raise and report concerns and could give us examples of where they had done so. There was a dedicated social worker for Primrose and Clover ward and staff could name them and give examples of when they had sought advice.

We did observe staff, and we saw staff interacting positively with the patients. All the staff members we spoke to were aware of safeguarding and could outline what role they were performing and the safeguarding risks present.

Between July 2023 and July 2024 the service reported 116 safeguarding alerts across all 6 wards. There had been a significant increase in safeguarding alerts between April and June 2024, which accounted for 47 of these alerts. The service had identified that this increase was in relation to 3 specific patients, 2 on Primrose ward the Psychiatric Intensive Care Unit. The two patients created 32 of these, 16 in May and 16 in June.

The service provided safeguarding training for both adults and children. There were 3 training courses for different staff groups. Of the 243 staff required to do safeguarding children and adults (C3), the course had a compliance rate of 75.3%. The other two courses were higher, with the (C2) course having a compliance rate of 92.3% for the 13 staff needing to do it and 100% compliance for the (C1) course that 41 staff were required to do.

Safeguarding was discussed at ward level team meetings. Managers also discussed safeguarding issues as part of their daily morning meeting across the hospital.

Patients told us they were always involved in the development of their care plans and risk assessments and a number told us how staff had individualised their care plan at their request. Both patients and staff told us they had always had regular one to one sessions to discuss these.

They also told us they understood what staff should do when they became agitated, and they had discussed plans with staff to deescalate any incidents.

In May 2024 Primrose ward moved from its original location and Clover ward opened as an acute ward. From May 2024 there had been 61 incidents requiring a physical intervention or restraint, 21 on Clover and 40 on Primrose including 22 in June. Managers were able to provide us with a rationale as to why incidents of restraint had been higher on Clover and provided evidence to support this.

Managers were confident that staff would only use restraint where necessary and that staff could de-escalate incidents before requiring the use of restraint. They investigated all incidents and looked to identify trends to reduce the number of incidents. They completed blanket restriction registers and considered any potential blanket restrictions on their wards.

We reviewed 10 patient records including the patient risk assessments and plans. We saw that risk assessments were complete and when we cross referenced them with incident’s that had occurred, we saw they had been updated to reflect any changes in risk following those incidents.

There was a difference between Clover and Primrose ward. Patients on Primrose were happy with the environment on the ward which was well maintained but those on Clover pointed out a badly maintained en-suite and furniture that was in need of repair.

Senior managers were aware of the repairs and did have budgets and contracts with building specialists to begin the repairs. The clinical governance meeting minutes from July 2024 highlighted a theme from patient community meeting minutes as being “around continuous maintenance requests outstanding following the reconfiguration of the wards.” These minutes also highlighted that the lead maintenance was due to be leaving although a replacement had been appointed and a handover due to start, whilst also noting there was “further vacancies” within the department.

On our ward tour on Clover, we found mould in an en-suite where the wall met the ceiling. Black mould is a type of fungus the spores of which can be harmful and can cause people to develop respiratory issues. Black mould should be removed as quickly and safely as possible and steps should be taken to prevent it from growing back. We also saw chairs where the covering was badly cracked on missing, these were a potential infection control risk. We also saw badly flaked or missing paint in several different places within the ward.

The operational governance minutes for June and July 2024 listed significant numbers of environmental, cleanliness and maintenance issues across all wards. There were not clear timescales as to when issues would be addressed, with the issues for each ward being added as one action with a deadline of “ongoing”. There were issues that were highlighted in the June 2024 minutes which remained on the July 2024 minutes. Although senior managers were being made aware of environmental issues through the operational governance meetings, it was not clear that prompt and timely actions were being taken to address the identified issues.

During the assessment we reviewed both environmental and ligature risk assessments. These were generally well written. Staff knew about any potential ligature anchor points and mitigated the risks to keep the patients safe.
Staff had completed fire risk assessments for all buildings, and there was fire evacuation plans specific to each ward. All patients that needed them had personal emergency evacuation plans (PEEP) in place
Electrical and Gas checks were in place.

Patients told us they felt there was enough staff and generally they were able to take their leave when expected and if it was delayed staff ensured they could take it later.

They told us that planned leave for appointments was never cancelled. The wards were busy with patients coming and going on leave.

Staff told us that staffing levels were good, although there were still challenges as both wards were busy, staff felt they always had time to provide one to one support or support a patient’s leave. This supported what patients told us. Staff also told us that the staff team was supportive and that they received debriefs following incidents.

There was a full complement of staff, for example, occupational therapists, psychology support.

We saw that staff did engage with the patients; we saw them encouraging patients to join them in activities. All staff could describe the patient and the needs, likes and dislikes of that patient.

Staff were not up to date with all appropriate mandatory training. The organisation submitted mandatory training data which indicated that the compliance rates for some of the courses was low. Three of these courses were below 75% including therapeutic observation and engagement at 71.3%; culture of care and closed cultures awareness at 73.7%; and behavioural support at 74%. Safeguarding children and adults (C3) training was just above 75% at 75.3%. The mandatory training programme did include a range of modules suitable for staff and their roles. It was a concern that the therapeutic observation and engagement training was low because patients that we spoke to identified lack of staff engagement whilst on observations as an issue within the service.

The service had initially provided mandatory training compliance levels following the on-site assessment which indicated positive compliance rates with no courses below 75%.

The hospital was unable to break down staff vacancies to ward level but overall, there were a small number of vacancies which included 1 Nursing ,1 Chef, 1 Painter and decorator, 1.4 Consultant and 1 Secretary.
However, there were several vacancies in the occupational therapy team with 1 qualified therapist and 3 assistants in either a full or part time role.
Between May and July 2024, the hospital overall had 93 registered nurse shifts covered by bank staff, with no agency usage. This equated to 5.09% of registered nursing shifts being covered by bank staff.

For the same period, the hospital overall had 999 healthcare worker shifts covered by bank, along with 293 by agency and 101 by locum. This equated to 12.16% of shifts covered by bank and 4.24% by agency and locum.

The sickness levels for the overall hospital were not significantly high, with the average monthly absence figures for the 12 months prior to this assessment being 3.82%.

The service had similar turnover levels across the 12 months prior to this assessment without any significant increase or decrease. The highest months turnover was in December 2023 at 28.36%. The yearly rolling staff turnover rate was 23.66%.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

People were supported to have access to healthcare professionals to maintain physical and mental health

Although people were supported to access monitoring relating to medicines such as bowel and blood sugars, staff did not always ensure this was completed as required in care plans.

People had access to a pharmacist to ask questions about their medicines

There was no evidence that people’s behaviour was controlled by excessive and inappropriate use of medicines.

A Pharmacist attended the wards weekly to review charts and conduct audits. Staff explained how the pharmacist could be contacted outside of this visit if they needed support with medicines.

Doctors were available to review and prescribe medicines. People had access to the doctors on a weekly ward round.

Staff were trained to manage and administer medicines.

We examined 11 records and found medicines and related paperwork were stored securely. Staff recorded temperatures of areas where medicines were stored.

Controlled drugs were stored securely according to legislation and policy

People’s medicines records contained information staff need to administer safely such as allergies.

Medicines prescribed to be given when required (PRN) had clear indications and maximum doses recorded. Staff recorded the times that these medicines were given to ensure that the safe gap between doses was maintained.

Medicines were administered safely

For two people we saw that medicines were not always documented on the appropriate mental health paperwork. Staff were aware of this and were awaiting the doctor to complete the required paperwork.

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.

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.