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 last inspection we rated this key question requires improvement. At this inspection 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 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 were aware of the need to ensure that both patients and staff were kept as safe as possible. Recent changes to the service, including the staffing changes on each ward, meant that staff had to renew their familiarity with policies and the visions and values of the service. This led to an improved knowledge base for staff that led to improved relationships with patients. There was a clear reporting process, and a policy dedicated to learning and development that outlined the impact of incident reviews.

A recent visit to the service that included an integrated care board (ICB) member, and a member of PROSPECT, the Cheshire and Merseyside Adult Secure Lead Provider Collaborative for specialised mental health care, explored the culture on the forensic inpatient or secure wards, and noted an improvement in positive aspects that had been a concern previously. The assessment team also explored the learning culture at the service, finding that staff felt confident to report safety concerns to their managers and were confident they would be listened to.

Lessons learnt was considered a key improvement by managers at the service, stating that the increased use of staff meetings, bulletins, incident reviews and the Patient Safety Incident Response Framework (PSIRF) implementation meant that learning was prioritised, and compassionate engagement over any blame culture.

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 service utilised pre-admission assessment and care plan documents as the patient journey began at the service. These identified all possible risk factors to be considered, as well as creating an initial care plan designed to keep the referred patient safe and healthy. These were reviewed by the multi-disciplinary team, with possible onward consideration by the senior leadership team should there be aspects of the referral that might require adaptation of the approach to meeting the needs of the patient.

Staff used the Short-Term Assessment of Risk and Treatability Tool (START) for the assessment of risk of patients. Patient records were updated or reviewed at least monthly, but also when isolated or individual incidents occurred that led to changes is levels of risk. Each patient had a crisis plan, similar to a positive behavioural support plan, that was utilised to de-escalate situations that might arise involving the patient.

We attended meetings on the wards. On Daresbury ward we attended a 0915 hrs handover meeting and a ‘Board round’ meeting where an overview of patients was undertaken with an emphasis on matters of care and discharge planning, and consideration of relevant activities for each patient on the ward. The handover meeting included a review of incident reports, including physical health reviews of patients who had attended A&E, and any ward updates including changes in patient observations. The ‘Board round’ meeting was only introduced shortly before the assessment at the service, and staff told us that it had real benefit in that it was a ‘quick-fire’ meeting that supported multi-disciplinary meetings at the service.

The service had policies in place relating to risk prevention, including infection prevention and control, security, searching of patient rooms, and prevention of self-harm. We reviewed these policies and found them to be comprehensive and relevant.

We scored the service as 3. The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff 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 provider shared concerns quickly and appropriately.

Safeguarding training was mandatory at the service. On Daresbury ward, the data showed that safeguarding adults and children training was at 97.1%, Delamere ward was at 92.2%, and Oakmere ward was at 92.4% across all staff.

Staff we spoke with knew how to apply the safeguarding policy that was in place, and data collected by the Care Quality Commission showed that statutory notifications were being sent where necessary. During the assessment a meeting was held with senior leadership at the service, and it was revealed that all safeguarding referrals would be monitored and audited by the deputy Hospital Director. An increase in relevant and more directed information had been noted in the notifications; the quality of information had improved.

The safeguarding adults and safeguarding children’s policies were reviewed and noted to be comprehensive. The policies had been updated in October 2025 and February 2026 respectively. The ward managers of the three forensic wards were asked about their knowledge of the policies, and they were able to discuss recent changes and the direction of the policies. The services also had policies on reducing restrictive practice that identified ways to ensure that safeguarding considerations were met, as well as a management of violence and aggression policy. The policies included links to relevant national guidance and the Mental Health Act Code of Practice.

We saw safeguarding process posters on wards and flow charts in nursing offices. Managers described their relationships with local authorities as good and improving. This was confirmed by the organisational safeguarding enquiry held in February 2026 involving PROSPECT, the ICB and the local authority.

Staff were seen to be interacting with patients in a positive way, although the acuity on Oakmere ward on the day of assessment was very high. The changes just prior to the assessment and staff movements had upset some patients but staff were seen to be calm and positive.

Training also included knowledge of the Mental Capacity Act and Deprivation of Liberties. A recent Mental Health Act paperwork audit from January 2026, that was a full review of all Mental Health Act paperwork relating to patients, was found to be 100% accurate. Mandatory training in the Mental Health Act Code of Practice was in excess of 90% across the forensic inpatient or secure wards.

Over 90% of staff had had training in the Mental Capacity Act across the three wards. Staff had a good understanding of the Mental Capacity Act, in particular the five statutory principles

There were no deprivation of liberty safeguards applications made in the previous 12 months to protect people without capacity to make decisions about their own care.

The provider had a policy on the Mental Capacity Act, including deprivation of liberty safeguards. Staff were aware of the policy and had access to it.

Staff knew where to get advice from within the provider regarding the Mental Capacity Act, including deprivation of liberty safeguards should it be required.

Staff took all practical steps to enable patients to make their own decisions, we saw evidence in care records showing consideration of consent and capacity. Best interest meetings were held, when necessary, there was access to advocates for patients who wanted or required representation.

The service had arrangements to monitor adherence to the Mental Capacity Act. The service had particular guidance for the application of the Mental Capacity Act, “Mental Capacity & Best Interest Decision Making Factsheet & Guidance”, that was available to all staff.

We scored the service as 3. The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We saw evidence that staff in the forensic inpatient or secure wards were actively involving patients in their care, whilst being aware of risk to both the patient and staff. Each patient had a ‘Keeping Safe’ care plan that was updated and maintained on each ward. The care plan was a breakdown of the risks, current and past, including diagnosis, triggers for specific behaviours and what minimised such behaviours. It included a safety plan and how to implement, if necessary, room searches or pat downs with the minimum impact on the patients. Patient input was clearly necessary in completing these plans, and we reviewed patient records showing that these were updated as and when required.

The changes to the hospital site from 6 to 4 wards was deemed to have an element of risk. Managers were aware of the possible issues with the changes and issued a patient communication informing patients of the upcoming changes. Patients were encouraged to speak with staff and use forums to lessen the impact of the changes. 3 of the remaining 4 wards were regulated under the Forensic inpatient or secure wards assessment service group.

A Restrictive Intervention report compiled in February 2026 outlined the numbers of incidents at the service between 2024 and 2026. The figures were high across the (then) 6 wards; this was reflected in the previous inspection report and showed a massive variation between the wards in the number of restrictive interventions that took place. For instance, Daresbury ward had a total of 13 physical restrictive interventions in the 2-year period, whilst Delamere ward had 1054. Oakmere ward had 624 such incidents. The data demonstrated significant variation in intervention demand across wards, reinforcing the need for ward‑specific oversight, targeted staff training, and continued monitoring to ensure all interventions remained safe, proportionate, and compliant with national guidance. Staffing levels were increased on Delamere and Oakmere wards to ensure the minimum impact of disruption. In the month of December 2025 after the site changes had been completed, Delamere had reduced to just over 20 incidents, Daresbury ward had one incident and Oakmere ward had just over 70 incidents, reflecting the acuity on the medium secure ward. The planned changes to the hospital site had considered that there would a rise in incidents, and wards were staffed accordingly. The numbers rose in the month prior to inspection.

In the month of January 2026 there were 3 prone restraints on Delamere ward and 3 prone restraints on Oakmere ward, with 10 supine restraints on Delamere ward and 12 supine restraints on Oakmere ward. It should be pointed out that restraint can often begin in the prone position but quickly changed to the supine position.

There were two episodes of seclusion on Oakmere ward in the month of January 2026. Between January 2024 and February 2026 there were a total of 42 episodes of long-term segregation on the hospital site, with no long-term segregation on Daresbury ward, 9 on Delamere ward and 14 on Oakmere ward. Of the 42 episodes across the site, 39 episodes had been closed by the time of the inspection.

We reviewed 6 sets of care records on Daresbury ward, 2 sets on Oakmere ward and 4 sets of records on Delamere ward. Care plans and risk assessments were comprehensive and up to date, with relevant amendments made after incidents had occurred. Key performance indicator audits were completed at the forensic inpatients or secure wards. We reviewed the January 2026 audit for Daresbury ward and saw that environmental checks, medication audits, care plan and risk assessment audits and mental health act paperwork were amongst the checks successfully carried out with minimal or no problems encountered.

We saw evidence that patients were involved in their risk assessments and were kept informed about any updates or changes to those documents. Community meetings allowed for patient feedback regarding their views on the service, as well as less formal methods such as talking to staff or in multi-disciplinary team meetings. Patients had access to advocacy, and this was evident in care records.

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. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

We found a breach of the regulations in relation to safe care and treatment. The environmental ligature risk assessments for the wards were 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 wards, nor where they were situated.

The ligature risk assessments across the service were scrutinised, 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 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.

A tour of the wards showed that furniture was appropriate for the forensic inpatient or secure wards and was in good condition. A review of seclusion rooms found they met the standard required, with one seclusion room having been fully refurbished. Seclusion rooms were in use during the inspection, and secluded patients were not willing to talk to us during the review of the rooms. The seclusion rooms were shared between the forensic inpatient or secure wards and psychiatric intensive care unit. The service had a seclusion door risk assessment document that outlined actions to be taken when patients were placed in seclusion and included staff numbers and actions to be taken should a seclusion door not work properly.

Closed circuit television (CCTV) was utilised across the forensic inpatient or secure wards, as well as the use of parabolic mirrors situated to enable staff to see in real time what was happening on the wards. The wards were big enough to safely manage restrictive interventions or issues requiring room to manoeuvre for both staff and patients. Staff were equipped with personal alarms, as were the inspection team when we arrived on the wards. Oakmere ward was operating with high levels of acuity; every patient on the ward at that time (13) was on high levels of observations. Fortunately, the reconfiguration of wards meant that sufficient staff were available to support patients.

Ward resuscitation equipment was held in ward nursing stations, including an emergency bag and a defibrillator, both of which were regularly checked and audited. Emergency drugs in clinic rooms were regularly checked both by staff and by pharmacy audit.

We scored the service as 3. The evidence showed a good standard. The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The reconfiguration of the service from over 80 beds to a 51 bedded service meant that staffing figures for the remaining wards and patients were kept at a high level. Managers had access to a safer-staffing tool that allowed them to gauge the staffing levels needed in case of high acuity or high-level observations. On Delamere ward, there was a core staffing figure of 6 staff in the daytime and 4 staff at nighttime. This could be amended dependent upon acuity, high level of observations, or ward occupancy level changes due to leave for patients.

The ward nurses and staff had different roles allocated during the shift, including security nurse and nurse in charge. The wards in the forensic inpatient or secure wards used bank staff regularly, but agency staff were never used. All staff received the same induction and training.

Vacancies in forensic inpatient or secure wards were low, Oakmere and Daresbury wards had only one nurse vacancy each, whilst Delamere ward had a 0,14-nurse vacancy. All other roles were over-recruited to; the reduction in wards and retention of staff after reconfiguration likely being the reason.

Staffing levels allowed staff to have one to one time with patients, and this was reflected in care records. We saw no examples of patient leave being cancelled or ward activities being stopped due to staffing limitations. We saw an example on one ward where staff had to share information with a patient that the patient would be unhappy about. The patient became agitated and angry with staff, but staff quickly de-escalated the situation. Staff were introducing changes at the service to lower leave of absence to hospitals for long periods to prevent the removal of several staff from the ward for that time. The forensic inpatient or secure wards had adequate medical cover during both day and night. Mangers could adjust staffing to manage acuity on the wards. We saw nursing staff in the main ward area during the inspection, not always in the nursing station.

Mandatory training was audited, and figures on all three wards, on average, were above 90%. On Delamere ward the training figures for both sexual safety and the importance of clinical record keeping were below 75%, both standing at 67.2%. On Daresbury ward the same two subjects were slightly below 75%, at 73.2% and 61.8% respectively. On Oakmere ward, the medium secure unit, only the importance of clinical record keeping was below 75%, standing at 66.7%. Oakmere ward mandatory training included more subjects than the two low security units. Induction was seen to be carried out across the forensic inpatient or secure wards, with the induction course noted to be relevant and comprehensive.

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 three wards in the forensic inpatient or secure wards were all clean and tidy, although the bedrooms were personalised and the patients had their rooms the way they wanted them. This included lots of personal items, making it difficult for staff to clean effectively at times, but none of the patients complained when asked about cleaning on the ward. We saw cleaning staff on duty during the assessment, and cleaning rotas were checked and seen to be up to date.

The service had a quarterly combined health, safety and infection prevention and control checklist. The Oakmere ward checklist from 30 January 2026 was reviewed. This took into account fire prevention, electrical equipment, all internal areas for cleanliness and safety of flooring and furniture, as well as other aspects for consideration. The checklist asked staff to ask patients if they had any concerns about cleanliness and safety on the ward, and these were recorded and considered. The checklist was comprehensive and signed by the ward manager.

Staff had access to relevant hand gels and cleaning equipment in the event they were needed. The key performance indicator spreadsheet for Quarter 3 of 2025/2026 showed no hospital acquired infections such or outbreaks of infection. The service had an infection prevention and control policy that was up to date. All wards were up to date with mandatory training in infection prevention and control level 1 at more than 90%.

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 happen.

During the inspection we reviewed care records on all three forensic inpatient or secure wards. We found no medication issues during the checks, and we saw audits that the service had in place to ensure medication administration and prescribing followed good practice. A pharmacist checked medication and prescription charts every 2 weeks. The wards had medication champions who were staff members with the responsibility to monitor medication use on the wards. National guidance in the monitoring of medication on physical health was being followed at the service.

The forensic inpatient or secure wards tried to use distraction and de-escalation techniques to support a patient before consideration of medication. This was discussed in multi-disciplinary meetings and was part of the pharmacy oversight. A medication improvement plan was created for Oakmere ward in January 2026. This outlined the methods to improve medication safety, ordering, administration, clinic management, compliance with NHS guidelines, and effective use of the pharmacy provider live view. This aimed at improvements on the ward, including improving medication ordering, clinic management, nightly clinic checks, medication administration and omissions. The aims were designed to be measurable and auditable.

The service had a comprehensive rapid tranquilisation policy, records showed that this was being adhered to.

We reviewed clinic rooms and the storage of controlled drugs and medication, checking expiry dates and temperature-controlled fridges. Temperatures were monitored and the clinic rooms maintained a cool temperature. There was guidance available regarding sharps or needle stick injury, blood borne viruses, spoilt medication advice if temperatures were too high, and latex glove allergy (although no latex gloves were allowed on site).