Silverwood

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. This is the first assessment for this newly registered service, however the rating for this key question remains the same as when we last inspected the locations that sit within this assessment service group in January 2020. This key question has been rated good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a shared vision, strategy and culture that was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding and meeting the needs of people and communities.The Hospital had recently opened and the staff had been heavily involved in training on site in the first month of opening so staff were fully aware and engaged with the strategic direction of the hospital. The hospital was under continuous quality assurance planning with regular quality checks being carried out across all areas to monitor and improve and all wards were involved in the process.

Patients we spoke with were all aware that the hospital was very new and even though they reported feeling safe they recognised the wards were going through changes to make things more streamlined for them.

Staff said they felt well supported by the senior leadership team and that they were visible on the wards. Staff said they felt well supported by their immediate ward managers, ward managers were based on the wards and were accessible directly from the staff office so were able to respond immediately to concerns on the ward with patients or staff. We saw evidence of leadership competency, support and development. Senior leaders said that staff in management roles had received training on quality improvement methodology and that they were delivering away days for staff to improve visibility to the workforce.All members of the senior leadership team were clinicians and had experience of working in acute mental health services. There was safe recruitment of leaders in relation to fit and proper person requirements. There were structures in place for reporting and evidence of succession planning.

A Freedom to Speak Up Guardian regularly visited the wards and ward managers and staff said they were aware of the process for raising concerns. The freedom to speak up guardian provided an annual report to the trust to create an open and transparent culture of improvement and learning where raising concerns was welcomed. Senior leaders said the wards had an open culture, with staff feeling safe to speak out. The directorate scored highly in the provider’s 2024staff survey in being a compassionate and inclusive service and that staff felt they were part of a team.There was a whistleblowing policy in place and staff knew where to find this and how to use it.

Staff said they felt confident in raising concerns about poor professional practice or inappropriate conduct towards patients.

As part of the mandatory training, staff received equality, diversity and human rights training. Compliance was at 84% at the time of inspection. There was an equality and diversity sub-group who supported staff, for example, with experiences of racism from patients. The hospital had set up support networks for staff. These included a multicultural network and a network for lesbian, gay, bi-sexual and transgender staff.

Staff were able to apply to work flexibly. For example, staff could request flexible working agreements to account for personal circumstances such as caring responsibilities and health issues.

Managers put reasonable adjustments in place for staff members to help them carry out their role. For example there were staff who had shift timings changed to enable them to meet their caring responsibilities.

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 senior leadership team and the ward managers met regularly in safety huddles to review incidents, complaints and concerns and identify themes. Lessons learned were cascaded to staff via staff meetings and team bulletins. There was evidence of consistent governance relating to ligature, fire and security risks.

Staff said that the electronic record keeping system supported them in their role and that there were systems in place to manage fire safety and ligature risks on the wards. Ligature information was easily accessed by ward staff. When we discussed ligature risk with staff, they were aware of the high risk areas of the ward and had undertaken training in understanding how to manage the risk. The senior leadership team had considered how ligature training was better learned in a dynamic way and had carried out scenario based training prior to the hospital opening on how to safely manage this risk.

Ward managers and the pharmacist we spoke with outlined the systems in place on their wards to ensure effective governance in relation to medicines management.

Senior leaders said that there were processes in place to ensure oversight of incidents, complaints and concerns. Staff were engaged in the roll out of the Patient Safety Incident response framework management framework. This is a framework that sets out the NHS’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents for the purpose of learning and improving patient safety.

Ward managers showed us the system they had for monitoring mandatory training updates. We could see the Key performance indicator framework the service used which generated a Quality Dashboard for every ward which supported the ward managers to see at a glance what areas their ward was excelling in and which areas needed additional input.

The hospital worked well with other agencies including commissioning bed managers, health and social care professionals and the local authority safeguarding team. For example, the ward managers all understood the key priority areas for local safeguarding referrals. Staff engaged with their professional bodies and undertook specific roles within these organisations.

Senior leaders regularly engaged with external stakeholders, such as commissioners and Healthwatch.

The advocates attended the ward and were invited to patient meetings and the senior leadership team meetings. Advocacy information was widely available on the wards and advocates were provided with confidential spaces to meet with people.

In April 2025 all wards had engaged with a Care Excellence Accreditation Review and were allocated Essential Action Notices to recognise and improve their mandatory standards, the hospital had taken these steps as a result of concerns raised by people receiving the services at the Hospital.

Silverwood also had implemented a “Lessons Learned Workshop” which was a multi-agency event to reflect on the progress of the Hospital from a broader organisational perspective. Lessons from this meeting reviewed the milestones of opening a new Hospital but also moved on to look at the emotional and operational journey for staff and people receiving the service.

Ward managers and staff described effective systems for reporting and investigating incidents to ensure debriefs were offered to staff, feedback was shared and safety improvements were made in response to lessons learned.

Staff gave us examples of an improvement made due to lessons learned following an incident which included improvements to record keeping in relation to handover documentation.

There was evidence of staff engagement with quality improvement projects on the wards, they knew how to apply quality improvement methodologies and the aim was to embed learning culture on the wards.

Ward managers received safety alerts with information about lessons learned from incidents elsewhere in the trust.

Improvement initiatives were co-produced with input from clinical staff, ward staff, and patients, embedding a ward-to-board governance structure. Evidence of a learning culture was seen through initiatives like the lessons learned workshop.