Surrey and Borders Partnership NHS Foundation Trust

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• 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.

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 people’s needs were met through good organisation and delivery.

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 made sure people were at the centre of their care and treatment choices and decide, in partnership with them, how to respond to any relevant changes in their needs. Staff regularly met with patients to understand their views on care and treatment. These discussions took place in one-to-one meetings with nurses and in multidisciplinary team meetings. Staff monitored patients’ conditions and discussed any changes at handover meetings.

Ward managers described the measures that were in place to ensure people were supported with their protected characteristics, for example cultural needs or physical disability. Staff gave examples of how people were involved to ensure that their care meets their individual needs.

The service provided therapeutic and recreational activities to meet the needs and personal interests of patients. A timetable of therapeutic activities was displayed on the wards. Some patients said they had participated in music sessions, cooking, creative arts activities, visited the gym, played board games and watched films, however the overwhelming feedback from patients was that there was not enough activity to keep them engaged.

This hospital admitted patients from across Surrey for relatively short periods, usually less than one month. The purpose of the hospital was to stabilise patients experiencing an acute episode of mental illness. Throughout each admission, the hospital ensured that patients maintained contact with people in their local area. Staff had regular telephone contact with patients’ families and health professionals. Family members, bed managers and care co-ordinators were all invited to multidisciplinary team meetings. Staff supported patients to maintain contact with their families and carers. The service facilitated attendance by video link if people were unable to attend the hospital.

There was mixed feedback from patients regarding their experience of care provision, integration and continuity. Eleven patients were happy with the support they received on working towards discharge from the hospital. Two patients on Orion ward said they were feeling stuck and were not being appropriately supported to progress towards discharge.

Ward managers described the systems in place to ensure that patient flow was not delayed. There were effective systems to support communication with patients' community mental health teams. The clinical teams were streamlined and managed continuity of care for patients well. Each consultant now had two wards to support the streamlining of patient transfers between their wards if required for safeguarding reasons.

The service provided appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

Staff had access to the equipment and information technology needed to do their work. The nurses’ offices were well organised and there was always access to computers when required by staff. The ward manager office was connected to the ward nurse’s offices so they were available to support with accessing care records information when required.

Ward managers had access to information to support them with their management role. This included key performance information on the management of the wards, staffing and patient care. This information was presented and discussed in clinical governance meetings regularly.

Staff made notifications to external bodies as needed. The hospital wards submitted notifications to the Care Quality Commission in accordance with the requirements of their registration. The service submitted safeguarding referrals to the local authority.

Staff made sure patients could access information on treatment and local services. Staff explained that information was provided for patients if it was needed. Staff displayed information about safeguarding, infection control, the Mental Health Act, the independent mental health advocacy service and a list of mental health solicitors on a notice board on each ward. The service complied with the Accessible Information Standard.

Staff ensured carers, families and commissioners were regularly updated about the patient’s progress

We spoke with 17 patients across the four wards visited during the assessment. Patients told us that they were aware of the complaints procedure and how to use it.

The service made it easy for people to share feedback and ideas or raise complaints about their care, treatment and support.

Patients, relatives and carers knew how to complain or raise concerns. Patients said if they had any complaints, they would speak with nursing staff or the ward manager in the first instance.

The service clearly displayed information about how to raise a concern on the ward or to external regulators in patient areas.

Patients said that information about how to make a complaint was displayed on notice boards. Staff understood the policy on complaints and knew how to handle them. All complaints for the hospital were passed to the compliance team who facilitated the investigations.

Staff knew how to acknowledge complaints and patients received feedback from managers after the investigation into their complaint. Between the 1 April to the 3 June 2025 Silverwood received three formal complaints and 15 Early Resolution Concerns. The complaints and Patient Liaison officer reviewed the complaints and fed directly into the clinical governance structure to ensure that there was leadership oversight of the individual concerns and that they were responded to effectively.

Staff that we spoke with said an independent advocate regularly visited the wards to support patients. Ward managers, service leaders and staff said community meetings regularly took place on the ward. Ward managers and members of staff gave examples of carer involvement events which had taken place and described the systems in place for involving carers and relatives.

Staff made reasonable adjustments for patients – for example, people with mobility issues were provided suitable bedrooms, walking aids, shower chairs etc.

There was appropriate medical cover day and night, a doctor could attend the ward quickly in an emergency and were based in accommodation within the hospital so able to attend wards out of hours whenever required.

There were measures in place to support people with their protected characteristics. Staff showed us that the wards were accessible to wheelchair users and patients had access to spiritual support on the ward, including multi faith rooms.

All patients had access to advocacy and the advocacy service was engaged with patients within the wards. There were advocacy posters on all of the wards. Staff supported patients to access advocacy and provided a private rooms to ensure that meetings were confidential.

From data provided by the trust for the months March to April 2025, two wards had increased the average length of stay and two wards had decreased their average length of stay. The hospital leadership team was looking at what had made this happen and was working to decrease lengths of stay across all wards.

The service admitted patients from diverse religious and cultural backgrounds. Staff asked patients about their religious and cultural needs when they were admitted to the wards. There was a protected religious space on each of the wards for patients who wanted to pray. The hospital provided culturally appropriate food. The hospital also employed staff from diverse backgrounds. This meant the hospital was able to utilise the ability of staff to speak to patients in their first language whenever this was possible. The service provided interpreters to translate for patients if required. However, all information displayed on the ward was written in English.Over 88% of staff had completed mandatory training in equality and diversity.

The multidisciplinary team planned for each patient’s discharge and return to their local area. Staff ensured that appropriate arrangements were in place to sustain the patient’s mental health. This included liaising with health and social care professionals in the patient’s local area to ensure they had appropriate accommodation to be discharged to and that a package of care was provided by the local mental health services.

Of the 17 patients we spoke with, 12 patients were happy with the support they were receiving to work towards discharge from their wards. Five patients said they were able to take part in education during their time on the wards.