Arbury Court

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

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

Senior managers within the hospital did not always use governance process to effectively monitor, manage and take action to address identified issues in a timely manner. This did not ensure that the provider had appropriate oversight and monitoring of the care and treatment being provided.

However, we found systems to address ligature risks, patient risks and fire safety checks were actioned or recorded. There were performance management and audit systems and processes in place which ensured managers had up to date information on the performance of the service.

Staff felt supported by their colleagues and by ward managers, although some staff described that they did not feel there was a connection between the wards and the senior management within the hospital.

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.

Staff told us they felt supported and worked well with each other. They knew the managers well. Staff felt morale was good. This was diverse workforce, and they felt there were no incidents of racism, and they would be supported if they raised concerns about practices or individual behaviour.

At the last inspection the hospital had just recruited several staff from outside the United Kingdom and on this inspection, we spoke to them again, they felt they had been integrated into the hospital community and had not experienced any incidents of discrimination.

Staff told us the role could be stressful, but that they were managed and supported by colleagues and senior staff.

Senior managers had developed a new structure for quality reports which required managers to have already audited the data and have conducted their investigations prior to attending senior management meetings so no time was wasted on going over the already available data.

The ward managers we spoke to about the risk of closed cultures told us that staff took turns to work nights, so staff worked with different staff to prevent staff from always working with the same people.

Leadership for the Primrose and Clover came from the wider hospital senior management team. The managers of Primrose and Clover ward attended the same meetings as all the other ward managers at the hospital. Some staff on the ward’s felt managers were away at hospital meetings on a frequent basis.

Some staff felt the Senior Leadership Team were supportive and approachable, however other staff felt less supported by the organisation. Some staff felt that senior leaders only attended the wards when there was a problem.

Leaders told us they attended patient and staff forums where issues could be raised by those groups directly with them. They did attend wards and did do senior managers visits to all wards.

Staff supervision and appraisal compliance rates across the hospital were low for the three months prior to the on-site assessment. Data provided to us by the organisation indicated that, for June and July 2024, less than half of permanent staff within the service had received some form of supervision, whilst this was much lower for bank staff. It was not clear that senior managers had appropriate oversight of this or were ensuring that staff were receiving support and supervision as required. Staff that we spoke to on-site did not raise this as a concern, however, we only spoke to a small proportion of the total staff within the service.

We saw that all staff completed the hospital induction process prior to working on the ward. The staff survey identified that 91% thought they had the right training and 84% thought their manager cared about them.

Staff felt there was a positive culture on the wards. Managers told us the multidisciplinary teams worked well together.

We saw evidence that there were regular team meetings for staff to discuss any issues. All the staff we spoke with told us that they were confident they could speak up if they had any concerns about the way they or the patients were treated.

The hospital had recruited several nurses from overseas previously and they were now embedded into the workforce. None of the staff we spoke with raised concerns that they had been discriminated against or had needed to speak up about the way they had been treated as employees.

Elysium healthcare had speak up champions across its network of healthcare facilities. There was clearly displayed information about the service on display for staff to access.

There was a whistle blowing policy and managers confirmed they attended staff meetings. They examined staff surveys and incidents for any intelligence of trends which would identify inappropriate behaviour.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Managers had implemented new governance structures as well as restructuring the service provided by the hospital.
Senior managers outlined the challenges and potential risks they managed. They could describe how they reviewed these regularly to identify and manage concerns.
Managers told us they monitored incidents during clinical governance meetings and identified themes and trends which helped them to understand and reduce risk. They had oversight of governance issues for example, clinical notes, multidisciplinary team and service user meetings, learning and development, physical health, safe staffing and risk. They used the dashboards routinely to monitor performance targets.

Following the on-site assessment taking place, CQC requested data and documentation from the provider. During the factual accuracy process of the assessment reports, the provider organisation, Elysium Healthcare Limited, made CQC aware of an investigation into the data and documentation that was submitted to CQC, as concerns had been raised about the accuracy and validity of some of this information. Elysium Healthcare Limited subsequently confirmed that their investigation had been completed. Elysium Healthcare Limited provided copies of the correct data and original documentation to CQC following the completion of their investigation.

Senior managers within the hospital did not always use governance process to effectively monitor, manage and take action to address identified issues in a timely manner. This did not ensure that the provider had appropriate oversight and monitoring of the care and treatment being provided.

The operational governance minutes for June and July 2024 indicated that oversight and governance processes were not always efficient, effective or followed up appropriately. For example, in the June 2024 minutes it stated that the “supervision and appraisal database will be reviewed in the next meeting”. In the July 2024 minutes, this section only referred to appraisals and that the majority would be due for approval as there had been a “big push” for appraisals during the summer months of 2023. There was no indication that the databases had been reviewed. The originally submitted version of the June 2024 minutes to CQC read that the dashboards had been reviewed at that meeting and that the group were “happy with the compliance”.

Both the clinical governance and operational governance meeting minutes for June and July 2024 indicated that certain meetings and areas of work had not been completed due to low attendance or in some cases “lack of preparation”. It was not clear that governance processes were therefore always running effectively and in ways which enabled the appropriate staff to engage in these processes.

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.

It was not clear that governance processes within Arbury Court were always robust enough to ensure that data and documentation was being managed appropriately, or that issues within the service were being escalated and scrutinised effectively.

There was a clear framework of what must be discussed in team meetings to ensure that essential information, such as learning from incidents, was shared and discussed.

The provider had policies to guide staff in the day-to-day operation of the service. There was a standard agenda to ensure consistency, and meetings served a clear purpose and were well managed.

Managers had ensured the wards were staffed to safe levels and that patients were safe and treated kindly.

Staff undertook or participated in regular clinical audits to ensure quality, such as care plans, risk management plans and medicines audits. The audits provided assurance and staff acted on these results when needed. Audit findings were dealt with in a timely manner.

Staff understood the arrangements for working together and with other teams, external to the service to meet the needs of patients.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.