Arbury Court

On this page

• 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

This means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last inspection we rated well-led as requires improvement. At this inspection the rating has changed to good. Leaders had the skills, knowledge and experience to perform their roles. Staff knew and understood the provider’s vision and values and how they applied to the work of their team. Staff felt respected, supported and valued. Governance processes operated effectively. Performance and risk were managed well. Teams had access to the information they needed to provide safe and effective care. Staff collected and analysed data about outcomes and performance. They used this to identify improvements.

We have not awarded this service a score for Well-led.

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

We scored the service as 3. The evidence showed a good standard. The service had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The provider had introduced change across the entire site, resulting in the reduction of ward numbers and the patient numbers at the site. The forensic inpatient or secure wards were left with two low security wards and one medium secure ward. Staffing on these wards was increased due to the movement of staff from the closed wards, coupled with the changing of staff on wards to help change the culture within the site and the services.

The values for the provider were kindness, integrity, teamwork and excellence, and the new hospital director and staff at the service were clearly working hard to ensure that these values were met on site. During the inspection of the service, we considered a recent cultural review by independent staff of the provider into the perceived closed culture at Arbury Court (completed in June 2025), as well as findings by another external lead provider collaborative. The independent review had been undertaken after findings from the previous inspection and actions of some senior staff during that inspection.

The findings of the independent review showed a closed culture that required immediate action to turn around the situation at the service. The challenges had been met and the changes implemented to try to amend the culture. Staff told us that they were still not sure about the pace of the change, but we were also informed that the service was now a better place to work. Patients struggled with the changes, as they felt that the relationships they built with certain staff were no longer in place. Many of those staff had left the service, but from what we observed during the inspection staff and patients were interacting in a respectful manner.

We saw no evidence of any lack of consideration around human rights, equity, equality or transparency. The changes that were made at the service needed time to be fully integrated into both the culture and the service, but the service was moving in the right direction both culturally and professionally.

Staff we spoke with knew the visions and values of the service and understood the aims. The new leadership team that introduced the changes to the site and the service had successfully communicated the aims and objectives of the changes.

We saw evidence of staff and commissioner involvement in taking the strategy for the changes forward. Staff were involved in meetings to discuss the changes and were able to raise any concerns or thoughts on the way forward.

We scored the service as 3. The evidence showed a good standard. The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

The re-organisation of the service had brought change on a large scale, but we saw evidence of communication between management and both staff and patients that indicated the direction it was taking. Leadership competency had enabled the service to adapt to the change, and a staff member told us that management changes had been effective. Another staff member said that they believed that staff should be rotated every 2 years, and another staff member said they were happy to see the improvement in the service. We saw evidence that patients had been informed about the changes prior to the implementation, also giving the patients the chance to respond and give their views on proposed changes at the service.

Minutes from the external PROSPECT meeting in January 2026 highlighted the positive practice at the service and praised a new wellbeing committee that had strong patient engagement. The new management team at the service had a positive impact, suggesting that the recruitment and approach of the leadership team was robust.

Staff we spoke with were complimentary about the new management team, and we were told that they now felt able and confident to raise issues without concern to senior management; they felt that they were listened to. We were told that there were no cases of bullying or harassment within the staff at the service, and staff confirmed this when approached. Staff told us that the changes at the service were still impacting on both staff and patients, but the ”new culture” felt more open than before.

The input from commissioners and PROSPECT meant that accountability was a strong consideration. Ward managers told us that they accepted this, and that they would act accordingly or as directed by senior management. The ward managers had changed wards during the changes at the service and were still getting settled at the time of the inspection. We were told that there was support from senior management, and we saw this during the inspection with the registered manager being personally involved in the initial “Board round” process to ensure that all staff were aware of the process and how to ensure it ran efficiently.

When speaking with the registered manager and his team, it was clear that they understood the service and were committed to driving the change that they felt was necessary.

We were told by staff that there were development opportunities for staff at the service.

We scored the service as 3. The evidence showed a good standard. The service fostered a positive culture where people felt they could speak up and their voice would be heard.

During the inspection, members of the inspection team were specifically tasked to discuss the culture of the service with staff and patients. We were told that prior to the changes at the service, it was felt that there was a senior leadership team that was not open and told staff and patients that they had to accept the way it was. We were told that the turnaround by the new senior leadership team at the service was effective in a short period of time; staff felt valued and listened to. We were told it was a better place to work, with great managers and leaders, but acknowledged there was a long way to go to fully implement the changes.

We were told that there had been “cliques” on wards and in leadership (small groups of staff), leading to a poor working environment, but that this had changed and was continuing to change.

The senior leadership team were ”fair but accountable” according to staff. There was a whistleblowing policy in place, and staff told us that they knew where it was on the intranet and how to use it.

There was a Freedom to Speak Up process, available to staff, external to the hospital. A visit to the service by a local authority safeguarding team was informed that the service was increasing the visibility of the Freedom to Speak up service by increasing visits to the service from 1 to 2 visits a month. There was a Freedom to Speak up policy and a whistleblowing policy.

Closed culture awareness training was mandatory at the service, and all staff had completed the training. During an unannounced visit by the local authority safeguarding team, patients told the team that they recognised that improvements had begun under the new leadership structure, though some felt the service was still stabilising following significant change.

Patients and carers had the opportunity to complete both a patient and family/friends/carers survey. The most recent family/friends/carers survey was completed in September 2025, 5 replies were received, and could be linked to the forensic inpatient or secure wards. The overall results were positive, albeit from such a small representation. The patient survey was measured across the site, so could not be linked to the specific forensic inpatient and secure wards.

Feedback from patient and family/friends/carer surveys were documented in the key performance indicators for the service and could be used to drive improvement.

We saw evidence of the provider informing patients and carers of changes to the service. Patients and carers could ask to speak with the senior leadership team to air any concerns.

The key performance indicators for the service also documented compliments received from patients and carers.

We scored the service as 3. The evidence showed a good standard. The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

The service had a high number of international staff working on the wards. Diversity, Equity and Inclusion training was completed as part of the mandatory training. Staff told us that they felt valued

The service had a comprehensive diversity, equity and inclusion policy. The policy stated that no individual should be treated differently to others because of their race, disability, sex, proposed or actual gender reassignment, sexual orientation, age, religion or belief, pregnancy and maternity, marriage or civil partnership or caring responsibilities. This policy had last been reviewed in July 2025.

We were told that there were opportunities for career development for all staff by both staff and management.

The provider had organisation-wide Employee Resource Groups (ERG) that could be accessed by staff, this included the women’s ERG, the Elysium Race and Ethnicity ERG and the LGBTQIA ERG. The Elysium Neurodiversity ERG promoted the use of reasonable adjustments for eligible staff.

Staff could apply for flexible working agreements.

We scored the service as 3. The evidence showed a good standard. The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

The provider had a governance policy in place; the policy was under review at the time of the inspection. The policy included responsibilities, implementation and reporting, and learning from incidents as well as incident management. The policy included reference reading material to be considered alongside the policy, this included government and NHS guidance as well as transforming care for people with learning disabilities.

Team meetings followed an agenda, designed to cover relevant issues that would affect the service. These included lessons learned, compliance, quality and audits, medication management, areas of improvement and achievement, safeguarding and ward specific actions. This allowed for implementation of learning from incidents, complaints and safeguarding cases.

Clinical audits were carried out by staff. We saw evidence of interaction between the service and external organisations. Management of risk was evident in records and in the service risk register. Staff could put forward items to be included in the risk register.

We saw no evidence of cost implications impacting on patient care.

We saw key performance indicators that were used to guide and target improvement in performance across the service and the site. The compilation of these indicators did not appear to be having an impact on the staff in gathering the evidence for the indicators. The key performance indicators included admission and discharges from the service, incidents and safeguarding alerts (lessons learned was also considered, but at service level by service audit), complaints and compliments received, care plans (co-produced with the patient) completed by the service and audited (this stood at 100%), appraisal and supervision figures and mandatory training. The key performance indicators also included management of key risks and any themes noted in behaviour or issues.

The key performance indicators also monitored numbers of viral outbreaks, such as Clostridium Difficile (C Diff), as well as any other viral outbreaks that might affect the site or service.

Ward managers told us they were made aware of findings from these indicators and acted upon them accordingly.

There were no indications of a shortfall in access to electronic equipment such as computers that might limit staff access to records. Team managers had access to relevant information that would enable them to fulfil their role and responsibilities to both staff and patients.

We scored the service as 3. The evidence showed a good standard. The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

Managers at the service told us that they had good relationships with other services who contributed to the overall welfare of their patients, including advocacy and social workers. A culture review carried out by the senior leadership team expanded on the need for the service to change, and these changes had been monitored and shared with both commissioners and local authorities.

The local authority safeguarding team, along with commissioners, maintained contact and oversight with the service about safeguarding incidents and care packages for patients respectively. We were provided with access to a spreadsheet that outlined the dates and times of meetings that had occurred with the commissioners who had patients in the care of the service, this included brief notes of the conversations with the commissioners.

Good practice was shared between wards, and this was discussed during team manager meetings. Mental Health Act reviews prior to the inspection identified that commissioners were involved in the care, treatment and discharge plans of patients at the service.

We scored the service as 3. The evidence showed a good standard. The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contribute to safe, effective practice and research.

The changes to the service and the culture review carried out by the service showed a willingness to implement new ideas and a new approach to the secure services, as well as the whole site. The overall change of staff on wards, new ward managers in place, and the attitude of the new senior leadership team indicated a drive toward improvement.

The introduction of the ‘Board round’ process by the hospital director meant that patient care was being considered on a more frequent basis that did not intrude on the multi-disciplinary team approach but added to the overall awareness of patients and their needs.

The provider was in the process of applying for inclusion in the Quality Network for Forensic Mental Health Services led by the Royal College of Psychiatrists, this includes some 133 standards for medium and low secure services to attain and follow. This would lead to opportunities for staff to participate in research for the benefit of themselves and patient care.

We were told that the provider was aiming to make the site a ‘showcase of sustainability’, with a group of staff and patients working to improve sustainability. We were told that the site now sent more volume to recycling sites than to waste sites, with recycling stations around the site for patients to use. Vehicle charging points were being scheduled for fitting on site, followed by solar panelling installation.