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.

We identified environmental issues on some of the wards, in particular on Delamere, where there were some large refurbishment projects still awaiting progression, such as the ensuite bathrooms, the kitchen and the laundry room. There were also some smaller maintenance projects and issues with damaged furniture and environments on some of the wards. Staff on the wards described that they were not always kept up to date on maintenance projects and how quickly things would be addressed.

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

However, 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.

This service scored 53 (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 could tell us about the patients and discussed why they 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.

The service’s referral and admission processes ensured that all essential information about the patient was received to determine if the patient’s needs could safely be met. Managers described how referral and admissions processes would be managed and in what ways the acuity of the wards would be considered.

Staff involved all the necessary healthcare and social care services to ensure patients had continuity of safe care, both within the service and post-discharge.

Patients that we spoke to in relation to admissions and discharges gave mixed feedback. Two patients stated they did not feel they had been orientated on the ward well during their admission whilst one patient noted that they did not feel informed about developments regarding their care. Some patients could explain what therapies they were in receipt of and described that they were involved in ward rounds.

Patients gave mixed feedback about their experiences of safeguarding and feeling safe on the wards. Some patients reported that they felt safe on the wards and had not experienced any violence or aggression, whilst there were other patients who did not feel safe on the wards, although this was due to the behaviours of other patients. We spoke to some patients who did not feel that staff always responded appropriately when they had reported concerns to them.

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, although the compliance rate for the safeguarding children and adults (C3) mandatory training course was low at 75.3%.

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.

Information was available to staff on the wards about safeguarding and their responsibilities in relation to this. There was evidence in patient records that staff had made safeguarding referrals where necessary.

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 and 1 on Delamere.

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 gave mixed feedback in relation to the management of risk across the wards. Some patients felt that their ward was overly restrictive at times and that there could be language barriers between certain staff and patients. Patients described that staff were visible on the wards, but that they would often be busy and not always available to interact and support all patients on the wards.

Most patients spoken to during this assessment stated they had not been restrained whilst at the hospital. We spoke with one patient who had been restrained who noted that, whilst the restraint itself was distressing for them, staff managed it well and spoke with them afterwards. A further patient also gave positive feedback about how staff had managed a restraint with them, including individualised ways that staff were aware of and utilised to try to de-escalate the patient.

Staff were aware of the procedures and processes in place to manage risks on the ward. Staff that we spoke to could describe specific patient risks and how these were being managed. Staff described how they would make attempts to de-escalate patients where necessary and felt confident that, if restrictive interventions were required, these could be managed safely.

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.

We reviewed 17 patient records during the assessment. Each patient had a risk assessment that was detailed and up to date. Individual risks were well documented within these records and indicated joined up working across the MDT with the management of risk.

Each ward had a reducing restrictive practice register which recorded hospital wide restrictions along with any ward specific restrictions. The audit template had a column which prompted the reviewer to consider how patients were involved in the review and reduction of the restrictive practice, although this was not always fully explored or documented such as stating that patients were aware of the rationale for the restrictive intervention. This meant it was not always clear how and in what ways the service had informed or consulted patients on each restrictive practice.

The hospital produced monthly reports regarding reducing restrictive interventions which provided data on how often certain restrictive interventions were used on all wards for that month. These reports were reviewed at the monthly clinical governance meetings where themes and actions required could be identified.

Patients gave mixed opinions as to the ward environments. Patients were generally satisfied that the wards were clean and that the domestic staff did a good job. Some patients commented that they did not feel the wards were always clean.

Most patients did not raise any concerns about damage to the ward, although one patient noted that they had some issues in their bedroom which had not been addressed, including the bathroom door not shutting and a broken wardrobe.

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.

Senior managers stated that they were aware of the pending repairs and had budgets and contracts with building specialists to begin the repairs. They had actively been trying to recruit more maintenance staff. Managers had an implementation plan for the improvements to be made to the environment although recognised that this could not always be undertaken at the desired pace due to the need to prioritise certain works and the fact some of the required projects were quite large.

Staff we spoke to on the wards described that they were not always kept up to date on maintenance projects and how quickly things would be addressed.

We identified environmental issues on some of the wards, in particular on Delamere ward, where there were some large refurbishment projects still awaiting progression, such as the ensuite bathrooms, the kitchen and the laundry room. There were also some smaller maintenance projects and issues with damaged furniture and environments on some of the wards. These issues did not always contribute to a therapeutic environment for the patients.

Clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly.

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, for example, in the Oakmere ward update it stated there was “mould in the clinic” and this was again recorded in the Oakmere update in the July 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.

The wards were all single sex environments and therefore complied with guidance on eliminating mixed-sex accommodation.

Staff had easy access to alarms and patients had easy access to nurse call systems.

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 were fire evacuation plans specific to each ward. All patients that needed personal emergency evacuation plans (PEEP) had them in place

Electrical and Gas checks were in place.

Patients told us they felt there was always staff present on the wards and generally they were able to take their leave when expected and if it was delayed staff ensured they could take it later. Patients did comment that staff were often busy on the wards and this could impact on the capacity of staff supporting specific patient requests and engaging with patients. The patients we spoke to recognised that this was not due to a lack of staff effort or them wanting to support patients.

Staff told us that staffing levels were usually safe, although noted that there were challenges as the wards were busy which impacted on their ability to support patients. Staff felt they had time to provide one to one support or support a patient’s leave. Staff also told us that the staff team was supportive and that they received debriefs following incidents.

The ward managers told us they could adjust staffing levels daily to take account of case mix and could access additional staff if there were unforeseen staffing issues.

The wards were well staffed during the assessment although on some wards this included a lot of staff who were allocated to enhanced patient observations. This meant that, although there were staff present on the wards, they were often busy with observations or other tasks. Those staff on observations tended to be solely observing the patient and were not necessarily considering ways in which they might be able to engage with the patients in therapeutic ways whilst undertaking observations. The hospital was considering ways in which they could promote and support staff with encouraging therapeutic when allocated observations.

Whilst on Hartford ward, we observed a staff member attempting to start an activity but was not able to continue as no other staff were available to support. On Daresbury, we observed that patient 1:1s were taking place, although these had been delayed due to staff having to attend to an emergency. We later observed numerous positive interactions between staff and patients prior to lunch on Daresbury where staff were keeping patients engaged.

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%. Following internal concerns within the provider organisation in relation to some of the data that was submitted to CQC, the organisation submitted further data for mandatory training within Arbury Court. 9 of the 43 mandatory training course compliance rates recorded on the spreadsheet were lower than had originally been submitted to CQC.

The hospital provided overall vacancy data following the on-site assessment. The service had no health care support worker vacancies and 1 nursing vacancy. The service also had vacancies for 1 chef, 1 painter and decorator, 1.4 consultant and 1 secretary. There were 2 posts that were going through onboarding and due to start in August.

The service also had a number of vacancies in the occupational therapy team for 1 qualified therapist and 3 assistants in either a full or part time role. This was putting pressure on occupational therapist availability at the time of the assessment.

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’s care plans had information on how to support them with their medicines

People were supported to manage their own medicines where they were safe and wished to do so and people had risk assessments to show they were safe and capable to do so. However, for one person we found that there was no risk assessment saved in the electronic care system.

People were supported to access appropriate monitoring related to their medicines and their physical health, however for 3 people we found that the monitoring was not always completed as required.

There were systems in place for staff to obtain medicines out of hours

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

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 staff needed support with medicines.

Staff could not always explain the process for reconciling medicines when people were admitted to the wards. We found for one person that the person had to request a physical health medicine they were prescribed prior to admission because it had not been written on their chart.

Staff were trained to manage and administer medicines.

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.

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

People’s medicines records contained allergy information, however for one person we found that the information was not always correct across records.

Medicines prescribed to be given when required (PRN) had clear indications and maximum doses recorded. We saw that staff recorded the time these medicines were used to ensure that the safe gap between doses was left. However, for one-person prescribed paracetamol regularly we saw that the time was not recorded so it was not clear if the required time between doses had been left.

For one person we found that one medicine was not documented on the relevant mental health act paperwork.

Staff reviewed the effects of patient’s medicines on their physical health according to NICE guidance

Medicines safety alerts were reviewed and actioned by staff.

Medicines records were mostly completed accurately, however for one person we saw that a dose of medicine had been signed for under the wrong route of administration.