South London and Maudsley NHS Foundation Trust

Ratings - Forensic inpatient or secure wards

• Overall

  Good

• Safe

  Requires improvement

• Effective

  Good

• Caring

  Good

• Responsive

  Good

• Well-led

  Good

Our view of the service

Date of inspection: 17 June – 23 July 2025.

South London and Maudsley NHS Foundation Trust provides specialist inpatient forensic services for male and female patients detained under the Mental Health Act 1983, who have mental disorders and most of whom have a history of offending.

At the time of our inspection, the inpatient forensic service comprised 108 inpatient beds across 7 wards based at the Bethlem Royal Hospital in Beckenham, south London.

The forensic services also include the Ward in the Community and Forensic Intensive Psychological Treatment Service (FIPTS) based at the Lambeth Hospital. We did not visit these as part of our inspection.

This report is specific to the 6 medium secure wards located at River House and 1 low secure pre-discharge ward at Monks Orchard House within the Bethlem Royal Hospital:

• Thames Ward (15-bed male acute ward);
• Norbury Ward (12-bed male clinical decision unit and psychiatric intensive care unit);
• Waddon Ward (15-bed forensic intensive psychological treatment service for men with personality disorders);
• Spring Ward (15-bed female ward);
• Brook Ward (16-bed male assertive rehabilitation ward);
• Effra Ward (16-bed male assertive rehabilitation ward);
• Chaffinch Ward (19-bed male low secure pre-discharge ward).

We undertook a short-notice announced visit to the medium and low secure wards at the Bethlem Royal Hospital on 17, 18 and 19 June 2025 as part of a comprehensive inspection, across all key questions and quality statements. We have combined the scores for these to achieve the overall rating. The forensic services were previously inspected in 2018 and rated good overall. Following this inspection, the overall rating has remained good.

We found several areas of good and outstanding practice:

• The ward environment was well-maintained, calm, light and spacious.
• Patients and carers said that staff were kind, caring and understood their needs.
• There was a strong focus on relational security and the use of restrictive practices on the wards was minimal. Staff completed Seni Lewis training in the least restrictive practice, developed by the trust and named after a patient who died after an incident of restraint in 2010.
• The service remained part of the South London Partnership (SLP), a long-standing partnership of the 3 neighbouring mental health trusts. This arrangement helped to provide joined-up local care and facilitate patients’ contact with family, friends and local communities.
• Patients and carers were supported to provide feedback and were actively involved in developing the services.
• The service was implementing an opt out system for independent advocacy provision, meaning that every patient would receive advocate’s support automatically, but could opt out if they did not want this.
• There was an open and supportive team culture where learning was shared. Staff were positive about working for the service and the support they received from managers.
• Numerous quality improvement and research projects were taking place within the service, with a focus on reducing the inequalities for the forensic patient group.

However, we found 2 breaches of regulations in relation to safe care and treatment. Intermittent observations had not been carried out and documented in line with the trust observation and engagement policy. Seclusion reviews had not been completed consistently in line with the protocol for observation and record keeping and the Mental Health Act 1983 Code of Practice.

We have asked the provider for an action plan in response to the concerns found at this inspection.

We also found several areas for improvement. At the time of our inspection, there were shortages of occupational therapy and activity practitioner staff, which impacted the availability of activities on Thames, Norbury and Effra wards. Post-rapid tranquilisation (RT) monitoring for 1 patient in seclusion on Norbury Ward had not been undertaken in line with the procedure. We identified some inconsistencies in physical health monitoring and recording on Norbury and Chaffinch wards, including NEWS2 monitoring and some discrepancies between the electronic and paper-based records. We raised our concerns with the leaders, who shared action plans for addressing, or mitigating, these areas.

Mental Health Act and Mental Capacity Act Compliance

Mental Health Act

The service provided care to patients detained under the Mental Health Act 1983 (MHA). 96% of staff had completed mandatory training in the MHA. The MHA and its guiding principles were part of induction for new staff.

Staff had easy access to administrative support and legal advice on implementation of the Mental Health Act and its Code of Practice.

The provider had relevant policies and procedures that reflected the most recent guidance. Staff had easy access to local MHA policies and procedures and to the Code of Practice.

Staff stored copies of patients' detention papers and associated records. Consent to treatment authorisations were mostly up-to-date and reflected the patients’ needs.

Patients had easy access to information about independent mental health advocacy. Relevant updates were shared at weekly community meetings. The service was implementing an opt out system for advocacy, meaning that every patient would receive advocate’s support automatically, but could opt out if they did not want this.

Staff explained to patients their rights under the Mental Health Act and documented this in a timely manner. However, Section 132 rights for 3 patients on Norbury Ward were not consistently documented as reviewed at the required intervals.

Staff ensured that patients were able to take Section 17 leave (permission for patients to leave hospital) when this had been granted. However, some patients told us their access to the outdoor areas was limited due to staff availability.

Staff requested an opinion from a second opinion appointed doctor when necessary.

Mental Capacity Act

Over 96% of staff had completed mandatory training in the Mental Capacity Act (MCA) and this was part of induction for new staff.

The provider had a policy on the MCA, including deprivation of liberty safeguards. There was a designated MCA and Deprivation of Liberty Safeguards (DoLS) lead. The provider’s MCA team offered training and drop-in consultations to staff.

Staff took all practical steps to enable patients to make their own decisions. The service had arrangements to monitor adherence to the MCA and audited its application.

The provider’s MCA team and legal representatives were involved in any relevant court cases.

People's experience of this service

We spoke with 27 patients and 16 relatives/carers of patients across all 7 wards. We attended 3 community meetings.

Staff actively involved patients in their care and treatment, for example in chairing their own medication reviews and care programme approach (CPA) meetings. Each ward had patient representatives who chaired community meetings and attended meetings with the service leaders. We heard about numerous changes that happened due to patient feedback and involvement. For example, patients had been involved in developing the activity offer, visitors’ suite, contributed to strategy development, tendering processes and research. The Service User and Carer Advisory Group was recently recognised by a Royal College of Psychiatry award. Patients had contributed to developing local policies and procedures, for example on internet access, anti-bullying and takeaways. Recently, 10 patients across the service received training in quality improvement so they could participate in and lead projects.

Patients had opportunities to engage in meaningful activities, training and paid employment. However, patients on some wards reported more limited activities and reduced outdoor access.

Patients and carers said that they, or their relatives, felt safe on the wards and that staff understood their individual needs. Patients’ and carers’ feedback about staff was very positive overall. They described staff as kind, respectful, caring, supportive and non-judgmental. One patient said: “They give a 10/10 service to patients”. Carers said staff were welcoming and friendly when interacting with them and their relatives. During our site visit, we observed staff always present in communal areas, engaging with patients and responding to their requests promptly.

Carers could visit their relatives in dedicated visiting facilities and described the hospital environment as safe, welcoming and clean.

Community meetings took place weekly on each ward. Minutes of the meetings demonstrated that patients raised issues that concerned them, and staff followed these up.

Feedback about food at the hospital was mixed. Some patients said they liked the food choice on offer. However, others told us they were not happy with the quality or portions of the food. At the same time, patients could self-cater, order takeaways and choose meals in line with their needs and preferences. Patients were able to share their feedback with the catering provider at community meetings.

The service carried out regular patient and carer surveys about their experience and invited suggestions for improvement. The results of the recent surveys in 2025 showed that the majority of respondents were positive about their experience. The service took action in response to the feedback. For example, staff had introduced quarterly open evenings and tours of the service for families and carers.