During an assessment of Long stay or rehabilitation mental health wards for working age adults
The date of inspection was 19 to 21 May 2026.
Victoria Gardens is an independent service for long stay or rehabilitation mental health wards for working age adults, which admitted male and female patients. The service has 3 open wards: 2 male wards, Bluebell ward which had 9 beds and Roby ward which had 12 beds, the female ward was Dovecot which had 8 beds. There were also 4 self-contained flats that were part of the rehabilitation pathway, at the time of the inspection these were staffed by the male wards, however, the service had the flexibility to accept female patients into the flats. The service had a fourth ward, Sefton, which was closed at the time of our inspection.
During our inspection we toured the environments of the three wards including clinic rooms and one of the flats. We attended a handover and a multidisciplinary best interest meeting. We reviewed prescription charts and care records, spoke with 9 patients and 16 members of staff, which included psychiatry, psychology, occupational therapy, support workers and nurses, as well as the registered manager.
We previously inspected the service in April 2022. We rated safe, effective, caring, responsive and well led as good, the overall rating of the service was good. At this inspection we rated the service as good.
The service was focused on learning from incidents and had implemented Just Culture training to support staff to have open conversations and ensure learning from incidents was more effective.
Risk assessments were comprehensive and physical health monitoring was good. There were positive relationships within the multidisciplinary team and comprehensive involvement of all disciplines in patient care.
The service had a strong culture of quality improvement and projects were considered in a holistic way such as improving care, supporting rehabilitation and staff wellbeing.
Patients spoke positively about the service and the care and support they received from staff. Patients had access to a range of activities, as well as work and education opportunities.
Staff worked to ensure that patients in the service were empowered and had supported complex discharges to ensure individuals achieved the best possible outcome.
However, infection control principles were not always followed and in some clinic rooms there were gaps in cleaning records. Care plans were not always personalised and did not reflect patient’s individual rehabilitation aims and discharge plans.
Also, some changes within the service and the organisation’s change to staff polices had led to anxiety and lowered morale in the service.
Mental Health Act
The service admitted patients detained under the Mental Health Act 1983. Staff received training on the Mental Health Act as part of their mandatory training, the compliance rate at the time of inspection was 96.9%. They had a good understanding of the Mental Health Act, the Code of Practice and the guiding principles. The service had easy onsite access to administrative support and legal advice on implementation of the Mental Health Act and its Code of Practice, and relevant policies and procedures that reflected the most recent guidance.
Staff explained to each patient their rights under the Mental Health Act in a way that they could understand and repeated this as necessary, this was recorded appropriately in care records. Staff ensured that patients were able to take Section 17 leave (permission for patients to leave hospital) when this had been granted. Escorted leave was rarely cancelled and always re-arranged as soon as possible if unable to go ahead.
Each ward had patient information boards, which included how to access independent Mental Health Advocacy (IMHA). There were no informal patients during our onsite inspection. Staff understood that informal patients could leave the service and described how they would manage this situation.
Regular audits were completed to ensure that the Mental Health Act was being applied correctly. This included a consent to treatment audit and section 132 (ensuring detained patients understand their rights) audits. These audits highlighted when new issues were identified, resolved or had been repeated.
Mental Capacity Act
Staff received and kept up to date with training in the Mental Capacity Act, had a good understanding of the five principles and were able to give examples of when capacity had been assessed. Staff training on the Mental Capacity Act and Deprivation of Liberty Safeguards was mandatory and the compliance rate was 99%.
Staff took all practical steps to enable patients to make their own decisions. There was evidence in care records that staff had involved patients in decision making and supported them to understand. During the inspection, we observed two best interest meetings regarding finance and diet, which included the multidisciplinary team, nursing staff, social worker, the responsible clinician, care co-ordinators, family and where required, specialists such as dietitians.
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. When patients lacked capacity, staff made decisions in their best interests, recognising the importance of the person’s wishes, feelings, culture and history.
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.