Victoria Gardens

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 assessment we rated this key question good. At this assessment the rating has remained as good. This meant people were safe and protected from avoidable harm. The service had a positive learning culture, learning was identified, shared with staff and action plans were in place to ensure oversight. All wards were safe, clean well equipped, well furnished, well maintained and fit for purpose. Staff knew how to ensure the safety of patients in the service and made referrals as required. Staff assessed and managed risks to patients and themselves well. The service used systems and processes to safely prescribe, administer, record and store medicines.

However, staff did not always adhere to infection control principles and in some ward clinics rooms there were gaps in cleaning records, expired items and printed out of date policies.

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.

The service used the Patient Safety Incident Response Framework (PSIRF) to report incidents. In the 12 months prior to inspection, the service had a total of 75 incidents. Incidents were categorised into levels of severity, level 3 – 5, with 5 being most severe. There were 67 level 3 incidents, 6 level 4 incidents and 2 level 5 incidents. Incidents ranged from aggression and violence, self-harm and medication errors, to health and security.

When incidents occurred, learning was shared with staff. There was a provider wide PSIRF safety bulletin. The service also had a quarterly lessons-learned round up, which was specific to recent incidents and risk within the service. This established system issues that had been identified and safety actions that were required to complete. There was evidence that changes had been made as a result of identifying areas for improvement. For example, the process for restricted items had been strengthened by highlighting the issues with consistency across day and night shifts, ensuring a security nurse was allocated during breaks on the ward and re-emphasising security processes in upcoming training sessions. The service also had an action plan in place to address the areas for improvement identified in the PSIRF process.

Staff we spoke with were aware of what incidents to report, how they should report and how to get support if they were unsure. Staff reported all incidents that they should report.

Staff understood the importance of duty of candour. They were open and transparent and gave a full explanation when things went wrong. There had been only one incident where staff completed duty of candour in the last 12 months, which was investigated, actions identified and the patient received an open and honest response to the incident.

Staff and managers confirmed that they received a debrief after an incident and could access support following a serious incident. This included swarm huddles (a meeting occurring immediately after the incident to analyse what happened, how it happened and how risk could be reduced), supervision and reflective practice. However, the safeguarding audit had raised that this needed to be recorded better.

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 had a clear inclusion and exclusion criteria for the service; each patient was reviewed individually to consider their suitability in the service. This included risk, treatment options and the individual’s willingness to engage in rehabilitation work. This ensured that the patient’s needs could be safely met.

The service had an admission checklist with specific timelines to ensure that staff gathered all essential information regarding the patient in a timely manner. Prior to admission, the individual’s section paperwork and where applicable Home Office warrant for transfer was requested and the ward’s nursing team was given the opportunity to read the pre-admission assessment. On the day of admission, the patient was orientated to the ward, physical health checks were completed and the responsible clinician reviewed the patient. Within 7 days of admission, START (Short-Term Assessment of Risk and Treatability) assessments and additional care plans would be completed, including PBS (Positive Behaviour Support) plans and the patient would meet their primary nurse.

Staff involved all the necessary healthcare and social care services to ensure patients had continuity of safe care, both within the service and post-discharge. This included social services and care co-ordinators. Managers and staff reported that there were good links between the service and external agencies. Commissioners told us that they felt Multidisciplinary team (MDT) meetings were thorough and staff were responsive when they raised questions or concerns.

The service also worked closely with the local Community Enhanced Rehabilitation Team (CERT) which was an NHS community provision who did in-reach into Victoria Gardens. They were able to support patients as they were transferring from the service and into the community and building up relationships with the community.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They 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 service shared concerns quickly and appropriately.

Staff were trained in safeguarding and the current compliance rate was 81.4%. Staff told us they knew how to make a safeguarding alert and did so when appropriate. Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act.

There were 30 safeguarding referrals made in the month prior to inspection, which included physical, neglect, psychological and financial incidents. The provider had a safeguarding policy in place, which supported staff to identify potential abuse and the reporting process for staff including the role of the local authority. The policy also set out how to support patients and the role of consent and best interests when making a referral. Managers completed an audit to review safeguarding to ensure that the policy had been followed, the service was communicating with local authorities, commissioners and CQC and identifying learning and outcomes from safeguarding referrals.

Children rarely visited the service, however, there was a dedicated room for family which was in the entrance of the hospital and did not require visitors to enter the main area of the hospital. The service had a clear process for children to visit the service.

Restrictive practices were kept to a minimum, some doors were kept locked due to safety reasons, such as the entrance to the ward and where specific risk had been identified. For example, on Dovecot ward there were timed vape breaks as patients needed to go downstairs to access the shared courtyard and on Roby the laundry was locked off due to identified risk.

Each ward had a restrictive practice register in place, which identified individual and blanket restrictions, who authorised the blanket registration, potential solutions to reduce or eliminate the restriction and any actions in place. Restrictive practice registers were completed monthly and reviewed by MDT bimonthly. They included hospital wide restrictions such access to energy drinks, vapes and lighters and ward specific risks such as supervised access to pool cues and balls. The service also completed a quarterly report on reducing restrictive interventions, which reviewed themes and trends, physical interventions, safeguarding and ongoing quality improvement projects.

Staff received training in restraint and the compliance rate at the time of inspection was 96.3%.

99% of staff had had training in the Mental Capacity Act. Staff had a good understanding of the Mental Capacity Act, in particular the five statutory principles.

There was no deprivation of liberty safeguards applications made in the 12 months prior to inspection.

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.

When patients lacked capacity, staff made decisions in their best interests, recognising the importance of the person’s wishes, feelings, culture and history. We observed a best interest meeting, which included MDT, care co-ordinators and family and discussions were focused on ensuring all practical steps were taken to enable patients to make their own decisions. All decisions around capacity were decision specific and staff involved different specialists where appropriate. For patients who might have impaired mental capacity, staff assessed and recorded capacity to consent appropriately.

The service had arrangements to monitor adherence to the Mental Capacity Act. Staff audited the application of the Mental Capacity Act and took action on any learning that resulted from it.

We scored the service as 3. The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. Staff assessed and managed risks to patients and themselves well and followed best practice in anticipating, de-escalating and managing challenging behaviour. Staff used restraint and seclusion only after attempts at de-escalation had failed. The ward staff participated in the provider’s restrictive interventions reduction programme. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

During the inspection we reviewed 14 risk assessments and risk management plans which were comprehensive and regularly reviewed. There was a focus on current risk, but historic risk was also considered. Various tools were used to create risk assessments, including START and Historical, Clinical and Risk Management-20 (HCR-20). Risk assessments were trauma informed and were psychologically formulated. Staff we spoke with knew patients well and were aware of their individual risks.

In the last 12 months there had been 33 incidents of restraint, of which 1 was in the prone position. The patient was only in a prone position for a short period during a descent to the floor and was moved to supine to make safe. There were 13 uses of rapid tranquilisation, 5 periods of seclusion and no use of long-term segregation. Managers had recognised that improvements were required in the recording of the seclusion notes and had provided additional training and safeguarding to ensure staff were completing these correctly.

Staff involved patients in care planning and risk assessments, which was shown in the patient’s participation in discussions in multidisciplinary meetings. However, the patient voice was not reflected in the care plans, or the individual’s strengths and progress in recovery. Ward manager care plan audits had highlighted the lack of patient voice as an area for improvement.

Patients we spoke with understood their care and treatment., They knew about their goals of recovery, they felt that they could give feedback on their care and treatment and their opinions would be listened to. When required, patients could access easy read and information in other languages. Staff enabled patients to give feedback on the service through community meetings and regular patient surveys, including a survey on the admission process.

Staff enabled patients to make advance decisions (to refuse treatment, sometimes called a living will) when appropriate, this was part of the admissions process and was to be completed within 7 days of entering the service. If the patient declined this was recorded.

Staff ensured that patients could access advocacy. There was an advocate who regularly attended the service who was known by patients and staff and staff knew how to refer patients to advocacy when required. Information on contacting advocacy was also on the information boards in each ward.

We scored the service as 3. The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Staff completed regular risk assessments of the care environment and were specific to each ward. Ligature audits highlighted where there were potential ligature anchor points and staff had mitigated the risk adequately through observations, staff awareness or ensuring non-patient areas were locked. All staff had individual alarms.

The ward layout allowed staff to observe all parts of ward and where vision was obstructed, this was mitigated through the use of CCTV and observations. During the inspection we also toured one of the flats, it was well proportioned and open plan.

Wards were single sexed, although the male ward Bluebell and the female ward Dovecot shared a courtyard; this was always observed by staff, and part of the courtyard had been blocked off which patients could use as a single sex area.

There was one seclusion room for the hospital, which could be accessed by any ward. There was two-way communication available, with clear observation panels, a digital clock and toilet and wet room facilities. Outdoor windows had privacy blinds built, and the room was spacious, well-ventilated and well lit.

Each ward was fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly.

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

In the 12 months before inspection, 2.5% of shifts did not meet establishment numbers. On these occasions support was provided from other wards, ward managers, or site coordinators. On some occasions the ward was also supported by the presence of the occupational therapy assistant (OTAs) being on the ward as they were able to provide additional support. Staff spoke positively about the OTAs being based on the wards as it provided increased access to activities for patients. However, as each ward had a designated OTA, if one was off then the activities offer was reduced, and OTAs were sometimes used to support the health care worker role.

The wards had safer staffing numbers, however, some managers and staff felt this was not always reflective of the staffing required on the ward, particularly when acuity was higher. To ensure that patients received an equitable amount of escorted leave, leave was timetabled, but this meant it might be limited to only 3 hours escorted leave a week.

However, where necessary managers deployed agency and bank staff to maintain staffing levels. In the 12 months before inspection, 7.42% of shifts had been covered by bank staff, and 1.53% of shifts had been covered by agency staff. When agency and bank nursing staff were used, those staff received an induction and were familiar with the ward.

There were no current vacancies for nursing and health care worker staff across the 3 wards and 4 flats. There were vacancies in the psychology team which included a 0.6 whole time equivalent (WTE) psychologist and 1 WTE psychology assistant. Both positions had been offered to successful applicants at the time of inspection. Other vacancies included 1 WTE lead social worker and 1 WTE handyman/driver which were out to recruitment. 1 WTE lead administrator had been successfully recruited and was due to begin induction in June 2026.

Sickness in the service was relatively low, the average total was 4.18%, with 2.62% of absences being short term and 1.56% being long term. Staff turnover for the period May 2025 to April 2026 was at 16.15%, which totalled 20 staff. 5 staff had been temporarily transferred to other services following the closure of the Acute ward on the site. The service reviewed themes from staff who had left the service, with the majority of leavers moving for career development.

A qualified nurse was present in communal areas of the ward at all times, and staffing levels allowed patients to have regular one-to-one time with their named nurse. There were enough staff to carry out physical interventions (such as observations, restraint and seclusion) safely and staff had been trained to do so.

There was adequate medical cover day and night and a doctor could attend the ward quickly in an emergency.

Staff had received and were up to date with appropriate mandatory training. At the time of the inspection, overall completion rate was 95.8% for permanent and bank staff. Training included restraint and breakaway, conflict resolution, patient safety incident response framework level 1 and 2, immediate life support, ligature awareness and reduction, and physical health training. Only three modules had a completion rate lower than 81%. Food safety level 2 and dysphagia essentials for catering had a compliance rate of 66.7% due to 1 member of staff being off sick, and 55.6% of staff had completed Safe and Supportive Observations and Engagement as this was a new classroom-based session that was only recently rolled out to staff.

We scored the service as 2. The evidence showed some shortfalls. The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

Staff did not always adhere to infection control principles, as some staff were observed with false nails and nail varnish. This had been picked up in previous ward audits and appeared to be a repeat issue in the service.

However, staff maintained equipment and kept it clean. The ward areas were well maintained, had good furnishing and were bright and clean.

Cleaning records were up to date which demonstrated that the ward areas were cleaned regularly. Cleaning recorded included both the ward areas and patient’s bedroom checklists. We also observed the wards being cleaned during the inspection.

Regular audits were completed for each ward which included mattress and hand hygiene, and external infection prevention and control audits had also been completed for each ward. Infection Prevention and Control compliance was above 80% for each ward, and Bluebell and Roby wards were both above 90% compliance.

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning.

During the inspection we found some concerns within the clinic rooms. On Dovecot and Bluebell ward there were gaps in the cleaning records, on Bluebell there were gaps in March, and on Dovecot there were gaps in March, April and May. There were improvements on Bluebell, as there were no gaps in March, and on Dovecot there was one gap in May.

Bluebell and Dovecot’s clinics had out of date policies printed out, such as self-medication policy, informal patients’ protocol, rapid tranquilisation policy, and ligature management policy. Dovecot also had out of date printed copies of British National Formulary (BNF). This was raised with managers following inspection who confirmed that current in-date policies and BNF were all available electronically and the outdated policies should not have been printed out.

In Bluebell’s clinic room there were expired items including eye pads, compression stockings, urinalysis dipsticks and glucose control solution.

Controlled drugs were safely locked away. The service had processes and systems in place to ensure medicines were prescribed and administered safely. Records were kept on an electronic system that were reviewed and audited by a third-party pharmacy service. Patients with high dose antipsychotic medication had the required monitoring in place. The service had a policy regarding the management of controlled drugs and the self-administration of medication