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

This means we looked for evidence that people were protected from abuse and avoidable harm. At our previous inspection we rated this key question requires improvement. At this assessment the rating has remained as requires improvement. This meant some aspects the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed. The environmental ligature risk assessment for the ward was not fit for purpose, with limited controls and mitigating actions in place to reduce the risk of patients ligaturing on the ward. Staff were not always confident about what ligature risks were present on the ward.

However, there was a strong learning culture in the service, and they had introduced the Patient Safety Incident Response Framework to review and action incidents. Staff assessed and managed risks to patients and themselves well and worked with patients to ensure that they understood their risks. We observed good engagement with patients, their families and external providers to ensure that care planning was joined up and collaborative. The service used systems and processes to safely prescribe, administer, record and store medicines.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

We scored the service as 3. The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Staff we spoke with knew how to report incidents and were confident in identifying what incidents should be reported. There was a clear process for staff to follow and the provider had an effective incident reporting system. Managers reviewed the previous day’s incidents in a morning meeting. We observed one of these meetings and saw incidents were comprehensively reviewed to ensure actions taken were in line with policies, that debriefs for patients and wellbeing checks for staff had taken place and external authorities had been notified.

The hospital used the Patient Safety Incident Response Framework to review serious incidents and establish learning and good practice following an incident. The service had introduced a mandatory training module, and 100% of staff had completed this. Incidents were reviewed to identify system issues and safety actions which were to be shared with staff. For example, resharing policies and reminding staff on the importance of following processes to ensure patient safety. This learning was typically shared with all staff across both assessment service groups.

Staff could give examples of when learning had been shared, both internally and from other Elysium Healthcare locations. Staff were aware of the duty of candour and the importance of having open and honest discussions with patients and families when something went wrong.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The referral and admission process ensured that all essential information about a patient was gathered to ensure their needs could be safely met. Each referral was reviewed by the ward multidisciplinary team (MDT) to ensure that the patient was an appropriate admission, and they could be safely cared for on the ward. When there were concerns about safely meeting a patient’s needs, ward staff would escalate to the senior leadership teams to consider if adaptations could be made to ensure safe care and treatment.

During admission to the ward a full risk assessment was completed. Staff used the Short Term Assessment of Risk and Treatability Tool (START) during admission to assess individual’s risk, care and treatment needs, and staff had a good understanding of the service’s processes and policies. Within Arbury Court, there was a physical health nurse who was also involved in admission assessments.

We observed a ward round during the inspection and found that there was good external representation at the meeting, including family, carers, care co-ordinators and staff from their local mental health services. The discussion on patient’s care pathways was robust, patient risks were reviewed, as well as physical healthcare, and patients themselves engaged with the discussions. This was also reflected in the care notes. This helped to ensure continuity of care for patients, as the partnership working supported care planning and discharge planning.

We also observed ward staff making appropriate referrals to partners where required. For example, to the local authority to ensure continuity of section 117 aftercare provision.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Staff were trained in safeguarding; the current compliance was 100%.

Staff we spoke with understood how to identify safeguarding concerns, and how patients were protected from harassment and discrimination. There were clear safeguarding systems, processes and practices to protect people from abuse. The lead social worker worked alongside a safeguarding coordinator to review all safeguarding referrals on a daily basis, which ensured good oversight of any actions that were taken following concerns being raised. For example, the safeguarding lead informed us that they held a weekly meeting with the safeguarding lead in the local authority to review open safeguarding referrals to make sure all actions were followed up.

There were plans in place to introduce a bespoke safeguarding training package for staff which also included a ‘jargon buster’ intended to demystify language for ward staff. This package had already been developed and delivered to the ward managers and was going to be rolled out to all staff. There were also one page fact sheets developed for staff on a range of subjects such as the MCA / Best Interests decision.

We saw posters detailing safeguarding processes on display in public areas and on the wards.

We observed staff interacting with patients in a positive, friendly way and patients appeared to be treated well and did not display any signs that they were fearful or withdrawn when engaging with staff. For example, on Hartford Ward, we observed staff and patients engaging with each other in a friendly, happy way that showed that they were comfortable with each other.

The service had policies on restraint and blanket restrictions and regularly monitored these to ensure safe care and treatment, and the least restrictive options were used.

98% of staff had received training in the Mental Capacity Act and Deprivation of Liberty Safeguards.

We scored the service as 3. The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. Staff assessed and managed risks to patients and themselves well and followed best practice in anticipating, de-escalating and managing challenging behaviour. Staff used restraint and seclusion only after attempts at de-escalation had failed. The ward staff participated in the provider’s restrictive interventions reduction programme. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

There were high levels of physical interventions in the PICU, 120 incidents required physical intervention between December 2025 and January 2026. Within the hospital’s Reducing Restrictive Interventions report, the high levels had been noted. The service had been reorganised in December 2025, which included patients moving to a different ward environment, as well as changes in nursing and support worker staff which meant patients had lost some of their therapeutic relationships with staff. Staff were conscious of this and were working to rebuild and develop those therapeutic relationships.

In the last 3 months, there was one incident of long-term segregation, and 10 episodes of seclusion. The service had dashboards to review and monitor the number of patients in seclusion and long-term segregation and could respond appropriately if concerns were identified.

During the inspection we reviewed all 6 patient’s records and risk assessments. Risks relating to people were assessed and managed appropriately, with the involvement of the person, so they understood any decisions about this. Risk assessments about care were person-centred, proportionate, and regularly reviewed with the person or their representative. We observed this happening at the ward round with patients and their families, as well as their care coordinators. Staff held discussions with patients about their risk and how these could be safely and effectively managed. For example, one discussion centred around how a patient could access their laptop whilst on the ward safely.

People were informed about any risks and how to keep themselves safe and were confident staff knew how to support them to mitigate risk. One patient who was close to discharge was advised that they could access psychological support to develop a relapse prevention plan with strategies to help them cope with the move to an acute ward. Patients told us that they felt involved in discussions about risk.

We scored the service as 1. The evidence showed significant shortfalls. The service did not always detect and control potential risks in the care environment.

We found that the environmental ligature risk assessment for the ward was not fit for purpose. All risks identified in bedrooms were grouped together, which did not allow for differences between rooms to be addressed and mitigating actions to be individualised. For example, some ensuite doors were full height, while others had a gap between the top and bottom of the door. Some items that were listed did not pose a fixed point to ligature, and some ligature risks were not identified. There were limited controls or mitigations in place for high-risk ligature points other than observations or security sweeps, which potentially increased restrictive practices through observations. The actions also did not identify where maintenance work could be completed to reduce risks. The environmental ligature risk assessment tool was completed by the hospital’s health and safety lead, with limited clinical input, and was then reviewed monthly by ward staff. The assessment we reviewed on the ward was not dated or signed. Staff were not always confident about what ligature risks were present on the ward, and the ‘actions/mitigations’ listed on the assessment tool were not always followed. For example, the outdoor area was kept unlocked and accessible at all times, however the risk assessment’s mitigation stated it should be supervised at all times when accessed. This was a breach of regulation 12: safe care and treatment.

This was shared as feedback with hospital leaders following our inspection. They confirmed that a new ligature risk assessment template had been developed by the provider Elysium Healthcare in November 2025, however there were issues on the handover of this document between the previous senior leadership team and the current one. Leaders confirmed that staff had been booked on new training for ligature assessments and shared the new Ligature Point Risk Assessment Tool and Guidance.

The PICU had recently moved locations in the hospital, and at the time of our inspection, the ward did not have its own clinic room. If physical observations were being completed on the ward, staff would wheel the equipment to the patient’s bedroom or a side room to maintain dignity, otherwise the main clinic room located off the ward would be used. Plans were in place to change a meeting room on the ward into a clinic, this room was currently being used to store the physical health equipment.

The ward’s resuscitation equipment was kept in the nurse’s office and was made up of an emergency bag and separate defibrillator. The bag was checked weekly and the defibrillator was checked daily, however, there were three gaps in defibrillator checks in January.

The ward had two seclusion rooms that were used by the PICU and the Forensic inpatient or secure wards as necessary. The two rooms were opposite each other which meant that it was difficult to have a private conversation or manage noise if both rooms were occupied. One room had a hatch in the door to provide medication or nutrition, but the other did not, which meant that there was increased risk of having to restrain a patient when providing nutrition or medication if opening the door was not a safe option. The rooms used CCTV to support observation and had a clear view of a clock so that patients were aware of the time.

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure there were enough qualified, skilled and experienced staff. However, staff received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Managers used a safer staffing tool to calculate the number and grade of nurses and healthcare assistants required and were able to respond flexibly if more staff were needed. For example, when there was high acuity on the ward or a high level of enhanced observations.

Vacancies on the ward were low, there was a charge nurse vacancy of 0.08, and senior health care worker vacancies of 1.44 that were currently being covered by health care workers. Other roles were over recruited to, which allowed flexibility and decreased the need for agency cover.

Between November 2025 and January 2026 there were 31 shifts that did not meet the planned staffing requirements. During 20 of those shifts bank staff were utilised to support staffing. In those 3 months, there was no agency cover used on the ward.

Staffing levels allowed patients to have regular one-to-one time with their named nurse and their key workers, and there was a focus from managers and staff to ensure they were being offered regularly.

Staff shortages rarely resulted in staff cancelling escorted leave or ward activities, and in the last three months leave and activities had not been cancelled due to staffing levels. There were enough staff to carry out physical interventions safely, including observations, restraint and seclusion.

There was adequate medical cover day and night and a doctor could attend the ward quickly in an emergency.

Staff received an appropriate induction to the ward and refresher training where needed. Staff had received and were up to date with appropriate mandatory training, which included, basic and immediate life support, restraint, medicine management, reducing conflict and rapid tranquilisation. The overall compliance rate was 94.9%, and most mandatory training had a high level of completion. 100% of staff had completed basic and immediate life support, Oliver McGowan learning disability training, and safe administration of medication. However, three modules were below 75%, Infection Control Level 2 (66.7%), sexual safety (66%) and the importance of clinical record keeping (65.3%).

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The ward was clean and tidy, with suitable furniture that was well maintained. We observed domestic staff cleaning the ward thoroughly in the morning, and they confirmed that bedrooms were cleaned daily. We reviewed cleaning records for the ward and found them to be fully completed and up to date.

Staff had access to personal protective equipment when required, as well as hand gels and cleaning equipment if required in between regular ward cleanings.

Staff had access to policies on infection prevention control, and staff completed mandatory training on infection prevention control (IPC), infection control level 1 had a completion rate of 96%.

IPC audits were completed regularly, with an overall score between 83%-87%. Actions had been identified, such as improvements in the environment, maintenance and refurbishment. 6 IPC focus areas had been identified for 2026, which promoted education, promotion and early escalation.

We scored the service as 3. The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

During the inspection we reviewed all 6 patient’s records. All patients had physical observations taken during their admission and were reviewed as necessary afterwards. Ward staff were trained in phlebotomy and taking electrocardiograms (ECG) and could easily access the support of the hospital’s physical health nurse when required. Staff used the National Early Warning System 2 (NEWS2) to record patients’ physical observations. The completion rate for Safe Administration of Medicines Level 1 training was 100%.

A pharmacist attended the ward every two weeks to review and monitor prescribed medications, and conduct audits, and could provide support to staff if required. Ward staff also completed regular audits every week. Any actions from audits were recorded to be followed up and completed.

Medicines, including controlled drugs and related paperwork was stored securely and well organised. All medicines were in date and opened bottles were all labelled. Controlled drugs were stored securely according to legislation and policy. The emergency medications were stored safely and staff completed weekly checks of the emergency bags.

Staff followed good practice in medicines management by following national guidance and prescribing in line with legal authorisations. Medicine records were completed accurately. Doctors were available to review and prescribe medicines, ensuring it was in line with national guidance.