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 requires 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 could access up to date information on the performance of the service, although it was not clear that this was always utilised by management within the service to have effective oversight and to make necessary improvements.

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 61 (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 at a ward level and worked well with each other. They knew the managers well. Staff felt morale was good. There was a 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 ward managers.

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.

Managers described how work had been undertaken to ensure that the international nursing staff were appropriately supported and integrated into the service since the last inspection. Managers continued to monitor this and were taking action to manage some of the specific patient concerns about staff behaviours and interactions with patients.

Staff gave positive feedback about the ward management and described that they felt supported and involved by ward managers.

The ward managers stated that they received support from senior management within the hospital and attended regular hospital wide meetings.

Some staff on the wards felt the ward managers were away from the wards at hospital meetings on a frequent basis. Some staff felt the senior management were supportive and approachable, however other staff felt less supported by the organisation and this level of management. Some staff felt that senior leaders only attended the wards when there was a problem.

The hospital had some recent changes in management level positions and the overall structure which were still being embedded at the time of the assessment.

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 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 that we spoke to stated that they could raise concerns and knew how they could do this. Some staff reflected that they were not always assured that, where concerns had been raised, that actions were taken to address their concerns. This was mostly around staffing levels on the wards and the retention of staff.

Managers that we spoke to felt confident that ward staff would raise any concerns that they may have.

The service had an identified freedom to speak up lead that was external to the hospital. The provider had posters available for staff to advise them of how to escalate concerns and the options available for them to do so, along with a poster that identified who the freedom to speak up guardian was. The posters also indicated that this information was available on the provider’s intranet pages. The provider had a freedom to speak up and whistleblowing policy.

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 described how they reviewed these regularly to identify and manage concerns.

Managers told us that 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.

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.