Victoria Gardens

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 this key question good. At this inspection the rating has remained good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care. 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. Governance processes operated effectively. Teams had access to the information they needed to provide safe and effective care. There was a strong culture of quality improvement in the service.

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.

Staff knew and understood the provider’s vision and values and how they were applied in the work of their team.

For example, the service had a clear trauma informed rehabilitation model of care that established the rehabilitation pathway for patients. The service had also recently completed a restorative justice culture project. The aim of the project was to increase psychological safety of staff and patients by 10% by December 2026. This was to be achieved by increasing awareness amongst staff and providing bespoke training for managers. The outcomes gathered so far suggested that there was an increased understanding amongst staff and an increase in meaningful conversations about psychological safety. Leaders spoke about how this project would influence their approach to supportive learning.

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.

At a local level within the service, leaders were visible and approachable to staff and patients. Staff we spoke with told us that managers, including the registered manager were accessible. Staff spoke highly of the support provided by their team.

Leaders in the service had the skills, knowledge and experience to perform their roles. Leaders had a good understanding of the services they managed and were knowledgeable about the patients within the service. The service model ensured that leaders had clearly established the roles of each team, to provide effective rehabilitation and high-quality care for patients.

However, staff did not always feel respected and valued by senior leadership within the organisation. Staff morale had declined following changes to policies regarding overtime pay and pensions. The January 2026 staff survey also raised that staff did not feel that there were opportunities for career progression in 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.

The service had 3 Freedom to Speak up champions, and they had recently had 2 drop-in sessions in April to support awareness. Staff felt comfortable raising concerns about patient safety and felt they would be listened to and their concerns acted on.

Patients and carers had opportunities to give feedback on the service they received in a manner that reflected their individual needs. Patients were able to give feedback informally to staff, as well as during community meetings, and patient groups. There were regular patient and carer surveys completed in the service. There was also a carer’s forum, which allowed carers to give feedback.

Feedback from patients, carers and staff was collected to establish areas for improvement. The service had various action plans in place to address the areas for the service to improve.

The service also had patient representatives in groups, such as the sustainability group, which was part of a wider quality improvement project to improve sustainability at Victoria Gardens. The sustainability group was a driver of co-production in the service, through the additional projects such as ‘spring de-clutter’ and a garden allotment project. These also encouraged healthy habits patients could take into the community, such as gardening and appropriately disposing of items individuals no longer required.

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

The service had a Diversity, Equality and Inclusion group who put on regular events throughout the year to reflect cultural and religious occasions, such as Lunar New Year, Easter, Ramadan, World Africa day and mental health awareness week.

Managers put reasonable adjustments in place for staff members to help them carry out their role. The service offered flexible working such as reduced hours, not having to work nights and working different shift patterns.

The provider undertook equality monitoring of staff within the service to ensure it was diverse in its make-up and representative of the patient group. The service employed staff of varied ethnic backgrounds to ensure the staffing group was diverse. The DEI group had also provided training on protected characteristics to increase awareness. The provider also launched a #IAM campaign which was to support staff to be open about their culture and background.

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 acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

Staff undertook or participated in local clinical audits. The audits were sufficient to provide assurance and staff acted on the results. The audits had picked up areas for improvement, which reflected some of the shortfalls we had identified during the inspection. This included issues with care plans, such as the lack of patient voice, linking activities with rehabilitation goals and discharge planning, as well as staff wearing false nails, and not following IPC principles. Managers were aware of these issues and they had been highlighted as areas that required improvement, and action was being taken. 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. Other areas, such as gaps in the cleaning records for clinics had been identified, and we found there were improvements being made.

There was a clear framework of what must be discussed at a ward, team or directorate level in team meetings to ensure that essential information, such as learning from incidents and complaints, was shared and discussed. The service had a daily flash meeting where the MDT discussed the previous day’s incidents, admissions and clinical concerns. The service also had monthly governance compliance meetings that reviewed incidents, injuries, staffing and a monthly quality account which included patient experience, physical healthcare, staff support and governance.

Staff used a patient safety incident response framework (PSIRF) to report and investigate incidents, and changes were implemented in the service. Learning was shared in the service, and across the wider provider, and training was implemented when required to support this process.

Staff understood the arrangements for working with other teams within the provider, the service’s model of care also helped to reinforce this. Staff told us that there were good working relationships across the MDT, although it was raised that there was pressure on the occupational therapy and psychology leaders as they worked across Victoria Gardens and other services. Teams also spoke positively about the occupational therapy assistant attached to the ward, as it had increased understanding between roles, and improved access. Staff also had strong working relationships with external stakeholders.

Staff maintained and had access to the risk register at ward or directorate level. Staff at ward level could escalate concerns when required.

Staff had access to the equipment and information technology needed to do their work. The information technology infrastructure, including the telephone system, worked well.

Information governance systems included confidentiality of patient records. The electronic patient record system was password protected. Paper records were stored securely in locked cupboards in locked rooms. Information was in an accessible format, and was timely, accurate and identified areas for improvement.

The service had plans for emergencies, there was a business continuity plan in place, which established appropriate actions to take depending on the incident such as fire, loss of electricity and adverse weather. There was also a bed contingency plan that was due for review in May 2026, which advised on the transfer of patients to temporary accommodation following a major incident.

Team managers had access to information to support them with their management role. This included information on the performance of the service, staffing and patient care.

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 worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

Leaders and managers engaged regularly with external stakeholders such as commissioners. Following the inspection, we requested feedback from commissioners who worked with Victoria Gardens. Their feedback was positive, they felt that communication was regular, and staff shared information quickly when there was an incident. One commissioner said the service ensured there was a range of staff who were able to support when information was requested, rather than one designated staff member. They felt that MDT meetings were thorough, and if they had concerns, they were addressed quickly.

Patients and carers were able to give feedback on the service and changes were implemented because of this. Patients were also involved in service development such as one patient co-producing the trauma informed training package, sharing their experiences and practices that were traumatising or re-traumatising during inpatient stays and what staff could do to support or prevent this.

Following feedback from some patients that the outcomes of ward rounds were not clear, staff worked with patients to support how they received information. A ward round notes book was developed, that allowed them to discuss their progression and requests more quickly and take notes from the discussion.

We scored the service as 4. The evidence showed an exceptional standard. The service had a strong focus on continuous learning, innovation and improvement across the organisation and local system. They always encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

Staff were given the time and support to take opportunities for improvements and innovation and this led to changes. There was a range of quality improvement initiatives in place at the service, with the aim to improve governance, care and treatment, training, and care plans.

Victoria Gardens was highly commended by an external body the ‘Annual Recognition Awards in Trauma Research and Practice’ for their development of the trauma informed training sessions. The training delivery was accessible and fostered a deeper understanding of Adverse Childhood Experiences and trauma, using patient opinions on ward environments and restrictive interventions to make the training more impactful.

Within the service’s wider sustainability project, staff also completed a quality improvement project on clinical waste management. The aim was to reduce medical waste at Victoria Gardens by 20% by January 2025 and put several Plan-Do-Study-Act cycles in place to achieve this. This included revising the medication ordering processes, introducing short-dated stock audits and replacing plastic cups with paper alternatives. As a result, with increased structure medication waste decreased, as did medication waste costs and the high use of single use plastics in the service decreased.

The service had launched a Just Culture protocol aimed at making staff feel safer and more confident to speak up, instilling a culture of learning and improved staff wellbeing when they were involved in an incident. The outcome of the implementation and training resulted in an increased understanding and greater confidence that responses to incidents would be transparent, strengthening psychological safety for staff and quality of care for individuals.

Victoria Gardens also had Real Work Opportunities that the Occupational Therapy Team supported with to help develop skills with the patients. A job fair was held with Role Profiles, to allow patients to be interviewed for potential roles and skills sessions to develop with a Curriculum Vitae (CV). At the time of inspection, the service had 3 patients completing Real Work Opportunities.

The service was also involved in the provider’s Rehabilitation Network. This allowed providers to share learning and improvements across services throughout the provider.