Victoria Gardens

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

This means we looked for evidence that the service met people’s needs. At our last inspection we rated this key question good. At this inspection the rating remained good. This meant people’s needs were met through good organisation and delivery. Staff supported patients with activities outside the service, such as work, education and family relationships. The service met the needs of all patients, including those with a protected characteristic. Staff helped patients with communication, advocacy and cultural and spiritual support. The service treated concerns and complaints seriously, investigated them and learned lessons from the result.

However, discharge plans were limited, and some statements appeared to be copied across care plans.

We have not awarded this service a score for Responsive.

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

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure people were at the centre of their care and treatment choices and they did not always work in partnership with people, to decide how to respond to any relevant changes in people’s needs.

Patient care was based on individual needs and preferences. However, care plans did not reflect patient’s voice, or their individual strengths, even when MDT notes showed patients were engaging in discussions about their care and treatment. Managers were aware that care plans were not as robust or reflective of patient’s ongoing care and treatment as they could, as this had been picked up in quality audits. Managers had an ongoing open action to help improve the quality of the care plans. This included regular discussions at clinical governance to highlight were improvements where required in care plans, and discussing the how MDT input is best reflected in care plans.

Patients we spoke with felt involved in their care, they understood how activities and sessions with OT, psychology or social workers were helping them to develop skills for living such as cooking and finance. They were also able to describe what their goals were, and how they could achieve this. Patients also told us they felt they could provide their opinion and be listened to. Carers were involved in MDT meetings to ensure individual’s preferences were considered, and they felt listened to by staff.

Patients also had regular one-to-one meetings with their named nurse to support and empower patients.

Each patient had their own bedroom, with an ensuite bathroom. They all had access to keys to lock their bedrooms to ensure that their items could be kept secure.

We scored the service as 3. The evidence showed a good standard. The service understood the diverse health and care needs of people and their local communities, so care was joined-up, flexible and supported choice and continuity.

Patients had access to education and work opportunities. One patient was accessing courses at a local college, and they told us they enjoyed attending. Patients had access to work and volunteering opportunities in the community such as volunteering in local charity shops.

The service also had work experience opportunities such as making cards that were sold in the hospital’s reception, and grounds work. The money from card making went back into purchasing supplies.

Through the service’s sustainability and green space initiative, patients were encouraged to access the community through orienteering in the local area and on day trips to the Lake District and Formby Beach.

Staff supported patients to maintain contact with their families and carers. They were regularly invited to MDT meetings, such as ward round, Care Programme Approach (CPA) meetings and best interest meetings. The service also had a carers forum and ‘carer days’ to support their engagement with patients and the service.

Staff supported patients to access their chosen place of worship within the community.

We scored the service as 3. The evidence showed a good standard. The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

Staff made notifications to external bodies as needed. This included safeguarding alerts to local authorities and commissioners and sending notifications to the Care Quality Commission.

Information governance systems included confidentiality of patient records. All patient records were stored securely on an electronic record system. The service complied with the Accessible Information Standard and staff had access to a resource hub which provided guidance on the standards and easy read material. There was also a communication policy in place.

When patients entered the service, they received a service user information pack which contained information on the model of care, the MDT, restrictive interventions, patient rights, how to access advocacy, raise complaints and how to access local services in the community. The information pack also explained MDT roles such as psychology, OT and social work. This was available in an easy read format.

Staff confirmed that they were able to provide information in other languages as well as easy read. This was reflected in the communications policy.

Staff ensured carers, families and commissioners were regularly updated about the patient’s progress. Commissioners we spoke with told us they had regular communication, and the service responded quickly to requests for information.

The service also had carer information packs, which explained the visiting process, section 17 leave and information on confidentiality. There was also an information pack from the provider which set out a general understanding of how carers can support their loved ones and how carers can be supported.

We scored the service as 3. The evidence showed a good standard. The service made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. They involved people in decisions about their care and told them what had changed as a result.

In the 12 months between 25 May 2025 and 25 May 2026 there were 4 complaints raised with the service. 1 out of the 4 complaints was upheld. No complaints had been referred to the Ombudsman in the 12-month period. The complaint that had been upheld was due to be reviewed in the service’s governance meeting to identify how learning could be actioned.

Patients and carers we spoke with knew how to raise complaints and concerns. Patients received a written response to the complaint, which was also available in easy read format if required. Managers ensured that responses were received in a timely manner, the service expected complaint responses to be shared within 20 days. In 1 case this did not happen, and an explanation of the delay was recorded in the complaints log.

Staff we spoke with were aware of how to handle a complaint and knew the importance of protecting patients from discrimination and harassment when they had raised a complaint.

Staff received feedback on the outcome of complaint investigations and acted on the findings.

The service had also received 26 compliments in the 12-month period prior to inspection. This included words of thanks from patients, third party providers and external stakeholders. The service had also introduced ‘Shout Out Fridays’ which promoted weekly positive feedback on achievements and expressions of thanks across the service.

We scored the service as 3. The evidence showed a good standard. The service made sure that people could access the care, support and treatment they needed when they needed it.

Staff ensured the needs of patients with mobility issues were met. During the admission process considerations were taken when admitting patients onto Dovecot ward as it was on the first floor. This was to ensure safe evacuation in case of a fire. The service had lifts available to support patients who may have mobility issues. On Dovecot ward this ensured that patients had access to the courtyard, which was also accessible via a staircase. Patients could also access equipment to support mobility and falls prevention such as shower chairs. On each ward there was a shared bathroom with a bath. On Dovecot ward there was an identified risk for one patient to access this, and a grab rail was installed to support them stepping into the bath. The service was also looking to refurbish the bathroom, and a request had been made to fund this.

There was adequate medical cover day and night. A doctor could attend the ward quickly in an emergency and the hospital was within a reasonable travelling distance to the local acute hospital.

Staff ensured patients had access to post-discharge care – for example, section 117 aftercare, community mental health services and crisis services.

In the 12 months prior to inspection, there were no delayed discharges from inpatient wards.

We scored the service as 3. The evidence showed a good standard. Staff and leaders actively listened to information about people who are most likely to experience inequality in experience or outcomes and tailored their care, support and treatment in response to this.

Staff within the service and the wider organisation promoted a culture in which the people using the service felt empowered to give their views. The wards had regular community meetings which allowed patients to give feedback on the service, raise concerns and share compliments. Patients had regular one to one time with their named nurse where they could discuss treatment, and staff supported patient wellbeing during interactions. Patients had access to independent mental health advocacy services, who regularly attended the ward, and details were available in the ward communal areas.

Staff were trained in equality, diversity, inclusion and human rights. Diversity, Equity and Inclusion training had a completion rate of 99.2%.

The service’s flats were used as a step-down method from the rehabilitation wards, with individual recovery goals including arrangements for medication, cleaning, accessing the community, and electronic key fobs for free movement. The service also used the flats to model packages of care, to support patients and potential placements to understand their needs at discharge. For example, a patient who had been in forensic services for over 20 years was ready for discharge, but community placements would not support them due to historic risk. The service used the flats to model a package of care and how it would look in the community. After 6 months without incident the patient was accepted into a community provider who worked with Victoria Gardens to ensure effective transition.

We scored the service as 2. The evidence showed some shortfalls. People were not always supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

During the inspection we found that discharge plans were limited, and some statements appeared to be copied across care plans. Although care records showed that there were detailed discussions of patients’ discharge from the service, and close working with care co-ordinators and onward care providers, this was not reflected in the discharge plan.

However, staff ensured all relevant healthcare professionals and other relevant bodies were involved in planning the care and treatment of people with complex needs.

When a patient was admitted to the service, staff completed an advanced directives with the patient.