- Independent mental health service
Arbury Court
Assessment report published 24 July 2026
Contents
Ratings - Forensic inpatient or secure wards
Our view of the service
We inspected Arbury Court from 3 to 4 February 2026.
Arbury Court provides medium and low secure care and Psychiatric Intensive Care (PICU) for women aged 18 years and over with Personality Disorder (PD) and mental illness.
Arbury Court is a modern, spacious facility with extensive grounds for the patients. There is a dedicated occupational therapy and activities area with a patient shop, gymnasium, and salon. Each patient has a private en-suite bedroom, which can be personalised. Patients take an active role in the day-to-day working of the hospital through participation in meetings, staff recruitment, peer support, and volunteering in various vocational work roles within the hospital and the local community.
We carried out an unannounced inspection of all 3 forensic inpatient or secure wards at the service. The service had, prior to the inspection, undergone a reconfiguration of wards and staff, leading to a reduced number of forensic inpatient or secure wards. The inspection was the result of consideration of risk and to follow up on actions from the previous inspection, published in June 2025.
Arbury Court is registered to deliver the regulated activities: Assessment or medical treatment for persons detained under the Mental Health Act 1983 and Treatment of disease, disorder or injury. At the time of the inspection, the service was going through the process of registering a new Registered Manager.
We visited the following wards as part of the assessment:
Oakmere ward, a female medium secure with 10 beds
Daresbury ward, a female low secure with 10 beds
Delamere ward, a female low secure with 15 beds
At this inspection we inspected forensic inpatient or secure wards where we assessed 33 quality statements.
“Right support, right care, right culture” is statutory guidance that underpins our approach to assessing services for autistic people and people with a learning disability. It applies to providers who do not intend to offer services to people whose presenting need is their autism or learning disability, but plan to provide any of the following regulated activities:
- Personal care
- Accommodation for persons who require nursing or personal care
- Assessment or medical treatment for persons detained under the Mental Health Act 1983
Arbury Court’s policies and procedures reflected this approach. The provider Model of Care outlined learning disability services available. Oliver McGowan Mandatory Training was completed by all staff.
At the last inspection the following breaches were identified in the forensic inpatient or secure wards:
- We found that physical health monitoring was not always recorded appropriately, and there were inconsistencies between what staff told us they should be doing with what the records indicated. This also included inconsistencies across physical health care plans and staff not always following care plans in relation to this.
- 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 and the Delamere kitchen and laundry. There were also some smaller maintenance projects and issues with damaged furniture and environments on some of the wards.
- Staff supervision and appraisal compliance rates were low in the months prior to the assessment. Staff mandatory training compliance was also below 75% for some of their 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.
- 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.
In this inspection, we found that the previous breaches had been responded to accordingly. An action plan had been created and maintained showing progress against the findings of the inspection.
In the forensic inpatient or secure wards inspection, we found 1 breach of regulation in relation to safe environments and effective ligature risk assessment. The service was in breach of legal regulation 12 (2) (d) of the Health and Social Care Act (2008), in that the ligature assessments for the service were not accurate or relevant to the locations assessed.
We have asked the provider for an action plan in response to the concerns found at this inspection.
Mental Health Act
There was a Mental Health Act administrator at the service, supported by a lead administrator (a national role for the provider) and access to solicitors. The Mental Health Act administrator stated they were always training and learning, and in discussion was aware of the then upcoming changes to conditional discharge and the Deprivation of Liberty Safeguards guidance. Mandatory training figures across the service averaged
The service admitted patients under the Mental Health Act 1983. Staff received training on the Mental Health Act as part of their mandatory training, no ward was below 90% for this training.
The provider had relevant policies and procedures that reflected the most recent guidance, and staff could access administrative support and legal advice on implementing the Mental Health Act and its Codes of Practice.
Staff explained to each patient their rights under the Mental Health Act and repeated as necessary, recording it clearly in the patients’ notes each time. Staff ensured that patients were able to take Section 17 leave (permission for patients to leave hospital) when this had been granted.
Mental Capacity Act
Staff received and kept up to date with training in the Mental Capacity Act and had a good understanding of the five principles. Training on the Mental Capacity Act and Deprivation of liberties was mandatory for staff, and the compliance rate was above 90% for each ward.
For patients who might have impaired mental capacity, staff assessed and recorded capacity to consent appropriately. They did this on a decision-specific basis with regard to significant decisions, and staff recognised the importance of a person’s wishes, culture and history. Staff knew where to get advice from within the provider regarding the Mental Capacity Act, including deprivation of liberty safeguards.
People's experience of this service
Patients we spoke with had mixed feelings about the service. We spoke with patients who were in seclusion, long-term segregation, and across the wards. There were concerns raised about the recent changes and the movements of staff and patients within the service, some patients felt they had not been listened to during the consultation prior to the changes Patients told us they had access to advocacy, they had copies of care plans, choice of food, and that generally they were happy with the care they were receiving. Some patients said they felt safe on the wards, others said they were “bothered” by the new staff that they had to adapt to after the changes at the service. It was clear from speaking with patients that there were mixed feelings about the service, and that a lot of this was a reaction to the recent changes at the service.
A patient told us that their admission to the service was a “positive experience”. Another patient told us that they had a copy of their care plan, but felt it was “difficult to digest”, but felt that explanation in the multi-disciplinary team meetings were clear. We spoke with patients who had been secluded, and they told us that “everything was ok”, it was noted that patients were allowed their own bedding in seclusion rooms.