South London and Maudsley NHS Foundation Trust

Updated 13 February 2026

South London and Maudsley NHS Foundation Trust (SLaM) has an annual turnover of £701.1 million for the year ended 31 March 2025 and provides care and treatment for a population of around 1.3 million people. They employ approximately 6,635 staff who work across 240 bases. Staff provide services to more than 40,000 patients in the community and in 712 beds across 48 inpatient wards. The trust provides services the London Boroughs of Croydon, Lambeth, Lewisham and Southwark and also has a number of national services.

The trust provides community and inpatient mental health services for children and adults across its patch. The main sites are Maudsley Hospital, Bethlam Hospital, Lambeth Hospital and the Ladywell Unit in Lewisham however teams are also based across multiple other locations across the 4 boroughs.

SLaM is part of 2 integrated care systems (ICS), south east London ICS and south west London ICS. SLaM are in Segment 3 of the NHS National Oversight Framework as at Q1 2025/26 (mandated regional support and oversight).

We had previously inspected SLaM in June 2021. At that time, we had rated the trust overall as good and well led as good.

We undertook a trust level (well-led) assessment, which included an onsite visit on the 1 October and 2 October 2025. We also held 19 staff focus groups and observed board and all committee meetings between July and October 2025. We assessed all 8 of the quality statements in the well-led key question in this assessment.

Our previous inspection made some recommendations for improvements and the CQC wanted to see if these had been implemented. Since the last inspection there had been some changes to the board leadership – the CQC wanted to assess the impact of these changes.

This inspection took place at a time of significant pressures for healthcare services – especially those associated with crisis and acute mental health pathways. The CQC wanted to see how the trust was managing these pressures and working with system partners to support access to services. The CQC monitor Patient Safety Incident Investigations (PSII) and wanted to understand how the trust was addressing and learning from these incidents.

Prior to the well led review, the CQC had inspected 4 Assessment Service Groups (ASGs): acute wards for adults of working age and psychiatric intensive care units; community health services for adults; crisis and health-based places of safety; and forensic mental health services. The assessment of the community and crisis services were part of CQC's Adult Community Mental Health Programme. This programme of inspections contributes to CQC's commitment to inspect the standard of care in community mental health services across the country.

CQC informed the trust that we were considering whether to use our powers pursuant to the urgent procedure (for suspension, or imposition or variation or removal of conditions of registration) under Section 31 of the Health and Social Act 2008. This was due to concerns we identified during our visit to the health-based place of safety and our visit to the community-based mental health services for adults of working age at Lambeth Single Point of Access team. The trust provided a detailed action plan to address the concerns, so no further action was taken. We followed up themes from these inspections during the well led assessment.

We assessed all 8 of the quality statements in the well-led key question used when assessing an NHS trust using our current framework.

At this inspection we rated South London and Maudsley NHS Foundation Trust as requires improvement for the well led assessment. The rating had gone down from the previous inspection.

We identified areas for improvement across all 8 well-led quality statements. These areas were as follows:

• Further work was needed to improve the culture of the trust. Many staff we heard from before and during the inspection described a disconnect between front line staff and senior leaders and said they did not feel their experiences were heard or that their work is always appreciated. Staff told us that they no longer felt that they wanted to provide feedback through the staff survey or other means as they did not believe this would make a difference. This was reflected in the low completion rate of 39% for the 2024 NHS staff survey.

• Freedom to Speak up (FTSU) needs further promotion and resource. Some staff we spoke with still did not feel safe speaking up or confident that their concerns would be actioned. Whilst the trust was reviewing arrangements for speaking up it must continue to rebuild confidence with staff and put mechanisms in place to ensure staff feel psychologically safe to raise concerns and provide feedback. The trust also needs to ensure freedom to speak up processes are effective and be able to clearly demonstrate it has acted on concerns.

• There were not always effective working relationships between the trust and the staff networks. Work was needed to ensure all the networks feel valued and that issues of race and racism and disability are understood and appropriately addressed.

• The clinical leadership at a trust and directorate level was not always working well with some leaders not feeling that they contributed appropriately to decisions. Executive director portfolios and associated responsibilities meant that the Chief Operating Officer had direct control of a number of significant areas of work relating to operational delivery, estates and financial turnaround. This could inherently reduce the level of professional challenge from other executive directors. At a directorate level, members of the multi-professional team did not always feel able to adequately contribute to decision making. There was a need to ensure clinical leadership was reviewed, considering roles and accountability to allow all leaders to contribute effectively.

• Many staff described working in an organisation which is top down and centrally controlled especially in relation to the implementation of financial controls. There was a need for better communication, transparency and engagement with staff around changes due to financial turnaround.

• The board would benefit from being further developed and supported to work strategically together. This was recognised by the trust and work to recruit non-executive directors, effectively induct non-executive directors and undertake board development was underway but needed to be progressed further. The arrangements for board visits to services would benefit from being reviewed to ensure they are more meaningful.

• Governance needed to be strengthened particularly at board level and the sub-committees. Executive directors should be supported to follow the correct processes to ensure the right information is available at the correct time for consideration by the sub-committees and board. Governance arrangements for services delivered through partnerships needed to be strengthened. The inspection of inpatient services showed that records of restraint, seclusion, therapeutic observations, physical health checks were regularly not completed accurately which meant that assurance checks to ensure these were done safely could not be carried out robustly.

• The trust needed to align its clinical and financial strategies during the strategy refresh. There were opportunities to increase the utilisation of benchmark data to reduce variation and improve productivity and efficiency. Both strategies need to have proper consultation so there is clarity on planning assumptions and consequential service impacts.

• The delivery of key projects such as the replacement of the electronic patient record system needs to happen in a timely manner with clear line of sight and the jointly understood identification and escalation of risk. This must also be reflected in the trusts Board Assurance Framework.

• Whilst this was a strategic priority the trust needed to keep progressing its work to improve access to the appropriate treatment and support for people experiencing mental ill health, especially in a crisis. The numbers of people waiting over 12 hours in acute emergency departments was high compared to most other London mental health trusts. The inspections of crisis services found that too many people were waiting for MHA assessments. The trust needs to check the impact of the different initiatives taking place so progress can be monitored.

• The audit and risk committee did not routinely meet with internal and external auditors in private and did not therefore have their perspectives about the quality of the control environment. There had been delays in following up actions including recommendations of an external review of the implementation of capital projects. External auditors' recommendations that the trust should develop and implement a data quality framework to support its reporting and decision-making has not been actioned for 2 years.

• Responding to complaints was taking longer than the stated timescales and responses varied in quality. The trust was taking action, but further interventions were needed. This was highlighted at the previous inspection as an area for improvement.

• PSIRF (Patient Safety Incident Response Framework) had been implemented at the trust, however we saw significant delays in completing patient safety investigations and lack of clarity in how action plans were followed up. The trust has an improvement plan in place for this but there was still more work to do to embed processes and make necessary changes to reduce the timeframes for these investigations.

• Employee relations needed to improve. Staff raised concerns about the grievance process and how individual cases were addressed. Cases investigating poor staff attitudes including bullying and harassment were often not investigated appropriately, did not follow trust policy and protocols and were taking too long to conclude.

Our positive findings from the well led review included:

• Across our inspections it was evident that staff were committed, compassionate, hardworking and strived to provide high quality care and treatment to people using the services.

• The trust had strong partnership working at both a local and system level. This was demonstrated through various projects and work such as the new community mental health model in Lewisham.

• The trust remained at the forefront of mental health research in close partnership with the Institute of Psychiatry, Psychology and Neuroscience (IoPPN) and other research bodies. Staff across a range of disciplines have opportunities to undertake research. People who use the trusts services are offered opportunities to participate in research including clinical trials. However, staff should be able to articulate more clearly how research is directly leading to improvements in the services delivered to people accessing the trust.

• The trust has led on the development of the National Patient Carer Race Equality Framework (PCREF) which was driving improvements for service users who experienced inequalities in access to care and treatment. Directorate teams were in the process of embedding PCREF into practice to drive further improvements for local communities.

• The current strategy was embedded and early work on developing the next trust strategy was underway. This included appropriate consultation with people who use services, staff and stakeholders.

• Emergency Preparedness Resilience and Response (EPRR) and Business Continuity approach was embedded within processes across the trust and there was a strong desire to continually improve.

• Co-production with people who use services and carers had been prioritised by the trust and we saw clear examples where lived experience had impacted positive change in services.

• The sustainability lead was passionate and showed innovative working that not only promoted sustainability but also a connection to the organisation’s purpose as a mental health trust. It was also clear the board were engaged with and promoting the sustainability agenda.

Updated 28 April 2025

Overall Summary / Our view of this service

We carried out a comprehensive assessment of the acute mental health wards for adults of working age and psychiatric intensive care units (PICU) delivered by South London and Maudsley NHS Foundation Trust.

We decided to inspect this service as we wanted to follow up on the requirements and recommendations from the previous inspection in November 2023. There had been a total of 2 self-harm-related deaths in the acute and PICU wards in the 2 years prior to the inspection and we wanted to ensure that learning from these deaths had been implemented to improve care and treatment and maintain patient safety. Areas we followed up included therapeutic observations, carrying out emergency resuscitation, the use of restrictive practices (restraint, seclusion, rapid tranquillisation), and environmental safety, especially ligature points and visibility on the wards.

The trust has 18 acute mental health wards and four psychiatric intensive care units located on four sites – the Bethlem Royal Hospital, Lewisham Hospital, Lambeth Hospital and the Maudsley Hospital. All the wards are single sex. We inspected 14 wards across each of these locations.

The wards we visited were:

Three wards at Croydon - Bethlem Royal Hospital

• Tyson West- 17-bed acute – male
• Croydon PICU - 10 bed – male
• Gresham 1 – 20-bed female acute admission ward

Six wards at Ladywell- Lewisham Hospital

• Virginia Woolf- 16-bed acute - female
• Clare Ward- 17-bed acute – male
• Wharton Ward- 18 bed acute female
• Powell Ward- 18-bed acute male ward
• Evans Ward – 15 bed acute male
• Johnson Ward - 10 bed acute male ward

Two wards at Lambeth – Lambeth Hospital

• Luther King Ward- 18-bed acute male
• Rosa Parks Ward - 18 bed acute male

Three Wards at Maudsley- Maudsley Hospital

• Jim Birley Unit - 19 bed acute – female
• Eileen Skillern 1 10 bed PICU – female
• Lucas Ward- 11-bed female acute ward (newly opened in 2024)

The Acute wards and PICUs were last inspected on 7 and 8 November 2023. At that inspection we identified two breaches of regulation. These related to staff training, risk assessments and risk management plans.

At this assessment we identified breaches of regulation: 10 Dignity and respect, 12 Safe Care and Treatment, 14 Meeting nutritional and hydration needs, 17 Good governance and 18 Staffing.

We rated the service as Requires improvement. We found that improvements were needed in the completion of accurate records following incidents of restraint; completion and recording of therapeutic observations; offering debriefs to patients after incidents; training compliance for safeguarding adults and children; consistent identification and management of safeguarding; completion of nursing and medical seclusion reviews; recording of reasons to administer ‘as required’ (PRN) medicines; recording physical health observations using National Early Warning Score (NEWS) charts so that deteriorations and the persons health can be identified; ensuring staff engagement is consistent across wards and shifts; ensuring all patients had suitable access to drinks and snacks; ensuring staff are supported to be engaged in changes in service delivery; enabling staff to feel they are able to speak up and their concerns will be addressed; and having effective systems of assurance in place.

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

At this assessment, we also identified areas of good practice. These included significant improvement in risk assessment and care planning; staff teams working well together; an embedded quality improvement approach with several ongoing projects; and positive patient involvement in care.

During this assessment, the inspection team:

• Visited 14 wards across the 4 hospital sites
• Carried out an environmental tour of each of the wards and observed staff supporting and interacting with patients
• Spoke with 57 patients
• Spoke with 16 carers
• Spoke with 76 members of staff. This included ward managers and deputies, deputy head of nursing, community link workers, physical health specialist nurse, safeguarding leads, dual diagnosis practitioners, activity coordinator/leads, head of therapies, student nurses, matrons, registered nurses, support Workers, nurse associates, clinical psychologists, consultants psychiatrists, clinical pharmacists and technicians, mental health law team leaders, carers lead, occupational therapists, peer support workers, volunteers.
• We attended handover meetings, daily clinical care meetings, safety hurdles, ward rounds, community meetings, and activities.
• Looked at policies and procedures related to the running of the service.

Mental Health Act and Mental Capacity Act Compliance

Mental Health Act

Most staff undertook training in the Mental Health Act 1983 and demonstrated an understanding of its principles and application. This knowledge supported safe practice, ensuring patients’ rights were protected and that care was delivered in line with statutory requirements. Overall, 93.1% of staff had received training in the Mental Health Act. However, compliance in this training varied across wards. For example, 100 % of staff on Tyson West 1, Croydon PICU, Virginia Woolf, and Lucas had completed this training, compared to 75% on Gresham 1 Ward, which was below the trust’s target rate of 85%.

Staff knew who their Mental Health Act administrators were and how to contact them and had access to the Maze book.

Staff could access The Maze book, which was a guide to the Mental Health Act. It could assist staff at all levels to understand the Act.

Mental Capacity Act

Most staff had completed their training in the Mental Capacity Act. Overall, 91.6% of staff had completed this training. Staff appropriately assessed and documented patients’ capacity to consent on a decision-specific basis; we saw clear evidence of these in patients’ care records.

Overall Ratings Grid

Overall – Requires Improvement

Safe

Effective

Caring

Responsive

Well-Led

Acute wards for adults of working age and PICU

Requires improvement

Good

Requires improvement

Good

Requires improvement

Updated 24 April 2025

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.

Updated 4 April 2025

We carried out an inspection of the trust’s community-based mental health services for adults of working age on 10 to 20 June 2025. This inspection was completed as part of the CQC's Adult Community Mental Health Programme. We also inspected mental health crisis services and health-based places of safety as part of the programme. The programme of inspections contributes to CQC's commitment to inspect the standard of care in community mental health services across the country. We undertook a short notice announced, comprehensive inspection of this service, looking at all 5 key questions to assess if services are safe, effective, caring, responsive and well-led.

South London and Maudsley NHS Foundation Trust is part of the South East London Integrated Care System (ICS). The population of the South East London ICS area is approximately 1.8 million. This includes six London Borough Councils, which are unitary authorities. While Bexley and Bromley have relatively low levels of deprivation, Greenwich, Lambeth, Lewisham and Southwark have higher levels of deprivation. All six areas are more ethnically diverse than the national average, with all having a lower percentage of white residents.

The trust’s community-based mental health services for adults of working age are spread across 4 directorates, Lambeth, Lewisham and Addictions, Southwark, and Croydon and Behavioural and Developmental Psychiatry.

• Lambeth directorate delivers care and treatment to working age adults through an alliance. The alliance is a collaboration between five organisations: Certitude and Thames Reach (voluntary sector); NHS SEL Clinical Commissioning Group (CCG), South London Maudsley NHS Foundation Trust, and Lambeth Council.
• Lewisham directorate provides core mental health services for adults of working age who live in Lewisham.
• Southwark directorate provides core mental health services for adults of working age who live in Southwark, alongside the trust’s specialist services.
• Croydon directorate provides core mental health services for adults ofworking age who live in the London borough of Croydon alongside national specialist services including forensic mental health services, prison health, and neurodevelopmental disorders including learning disabilities, autism spectrum disorder (ASD) and adult attention deficit hyperactivity disorder (ADHD), and specialist services for people with psychosis.

The way in which services were organised and delivered varied across the 4 directorates and across different teams. This included differences in governance systems.

The inspection team comprised 4 CQC inspectors, 1 CQC analyst, 1 CQC senior specialist in mental health, 1 CQC deputy director, 3 CQC pharmacist specialists (also referred to as medicines inspectors), 3 specialist advisors, and 1 Expert by Experience (people who have experience of using or caring for someone who uses services).

During the inspection we:

• visited the Lewisham Neighbourhood 1 team, the early intervention teams at Lewisham and Lambeth, the Southwark assertive outreach team, the Lambeth single point of access team, the Lambeth Living Well Centre north focused support team, the community mental health teams at Croydon central and north and the Croydon assessment team,
• the medicines team visited 5 sites, where community mental health services, early intervention in psychosis services and various medicines clinics were held,
• spoke with 122 staff of various grades and roles,
• spoke with 12 people who used services and 7 carers,
• reviewed 52 care records for people who used services, including medicines administration and associated care records.

We last inspected the service in August 2021 when we rated safe and responsive as requires improvement and effective, caring and well-led as good. This led to the assessment service group being rated overall as requires improvement. At our last inspection we found breaches in regulation relating to managing emergency equipment, medicines management and the management of controlled stationery, mandatory training compliance, delays to Mental Health Act assessments and not meeting the target for assessing non-urgent referrals within 28 days.

At this inspection we rated the service as requires improvement. We rated safe, effective, responsive and well-led as requires improvement and caring as good. We found 8 breaches of regulation relating to:

• assessing and responding to risks for people waiting for services
• risk management processes, including completion of risk assessments and risk management plans
• the suitability of care environments
• person-centred care
• compliance with reading people’s rights under section 132 of the Mental Health Act
• effective governance, including monitoring and improving outcomes for people and
• completion of care records.
• The service still had delays to carrying out assessments under the Mental Health Act 1983.

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

However, the service had made some improvements and was no longer in breach of regulations relating to emergency equipment and management of controlled stationery.

Updated 4 April 2025

We carried out an inspection of the service’s mental health crisis services and health-based places of safety on 10, 11 and 12 June 2025 as part of CQC's Adult Community Mental Health Programme. The programme of inspections contributes to CQC's commitment to inspect the standard of care in community mental health services across the country. We undertook a short notice announced, comprehensive inspection of this service, looking at all 5 key questions to assess if services are safe, effective, caring, responsive and well led. We also inspected community-based mental health services for adults of working age as part of the programme.

South London and Maudsley NHS Foundation Trusts mental health crisis and health-based places of safety service have 4 home treatment teams (HTT) across its directorates at Croydon, Lambeth, Lewisham and Southwark. The service has a health-based place of safety at Maudsley Hospital and a crisis outreach service based at Lambeth.

The inspection team comprised of 4 CQC inspectors, 1 CQC senior specialist in mental health, 1 specialist advisor, 2 CQC Mental Health Act reviewers, 4 CQC medicines inspectors and 1 expert by experience (someone with experience of using or caring for someone who uses or has used mental health services).

In March 2024, the South London and Maudsley NHS Foundation Trust implemented the NHS Community Mental Health Framework for all service-wide mental health services. This included removal of the Care Programme Approach (CPA) and re-design of the key worker role to identify changes in people’s presentation more effectively.

During this inspection, we focused on services provided to adults between 18 and 65 years of age, in line with how we register assessment service groups.

Home Treatment teams (HTT) and the trust’s crisis outreach service (COS) provide support to people who have a mental health crisis outside of hospital. They also provide support to help facilitate early discharge from hospital to provide treatment at home.

Health-based places of safety are used if someone is detained under Section 136 of the Mental Health Act 1983. People can remain there for a maximum of 24 hours, plus a possible extension of a further 12 hours, until a Mental Health Act assessment is undertaken.

During this inspection, we undertook the following activities:

• Visited home treatment teams (HTT) in Croydon, Lambeth, Lewisham and Southwark
• Visited the crisis outreach service in Lambeth
• Visited the acute referral centre (ARC) at Maudsley Hospital
• Visited the health-based place of safety (HBPoS) at Maudsley Hospital
• Observed the environment of patient areas at the home treatment teams and the health-based place of safety
• Observed handover and quality improvement meetings
• Observed an acute referral centre caseload and bed management meeting
• Spoke with 48 staff members including consultant psychiatrists, junior doctors, clinical psychologists, occupational therapists, registered nurses, associate mental health workers, pharmacy staff and health care assistants
• Observed 3 HTT appointments
• Spoke with 14 people who had used services and 7 carers or relatives
• Reviewed 41 care and treatment records, including 6 records for patients who were currently or recently detained under Section 136 of the Mental Health Act (MHA)

We last visited the service as part of an inspection in August 2018 and rated the crisis services as good overall and across each of the domains. We did not find any breaches of regulation at our last inspection. There were several recommendations to improve the service. One of these was to continue to address the numbers of people spending more than 24 hours in the health-based place of safety. Another was to ensure that people on a section 132 clearly understood their rights. These continued to be a significant concern at this inspection.

At this inspection we rated the service as requires improvement. We rated safe, effective, caring, responsive and well-led as requires improvement.

We found breaches of regulation relating to:

• Reporting of incidents (Regulation 12)
• Use of inappropriate restraint (Regulation 12)
• Access to fresh air at the health-based place of safety (Regulation 15)
• Medicines management (Regulation 12)
• Ensuring people can access services in a timely manner (Regulation 17)
• Staff compliance in mandatory training (Regulation 18)
• The need for consent for people remaining in the health-based place of safety for over 24 hours (Regulation 11)
• Compliance with clinical supervision for staff working in the health-based place of safety (Regulation 18)
• Staff in home treatment teams not having access to working alarms (Regulation 12)
• Robust governance arrangements (Regulation 17)

Following this inspection, we raised concerns with trust leaders relating to the care and treatment of people using the health-based place of safety (HBPoS). This included ensuring people are detained under an appropriate legal framework, consent to treatment when Sections 135 and 136 of the Mental Health Act had expired and the use of incorrect restraint methods.

They provided an action plan which addressed the concerns raised. The actions included increased oversight of Mental Health Act Assessment waiting times by senior managers, immediate action to implement daily clinical risk screening by senior clinicians, screening of all urgent referrals to ensure there was no harm or risk of harm for people waiting for services and provided increased training for staff.

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

Updated 8 January 2016

We gave an overall rating for child and adolescent inpatient mental health services of good because:

• Staff were kind and treated the children and young people with dignity and respect.
• Young people were able to actively participate in decisions about their care and in decisions regarding the running of the ward.
• Most young people were risk assessed and received a comprehensive assessment of their needs on admission to ward and monitored throughout their stay.
• The wards had clear systems in place to mitigate risks to young people, such as with regards to medication and safeguarding.
• Staffing numbers were usually enough to meet the needs of the children and young people.
• Incidents were reported, reviewed and lessons learned through feedback to staff.
• Treatment and monitoring were based upon best practice from appropriate bodies, such as the National Institute for Health and Care Excellence (NICE). Young people had access to a range of therapies.
• All wards had wide-ranging multi-disciplinary teams and staff were well trained and supported.
• Young people were supported to meet their religious, cultural and sexuality needs.
• Complaints were responded to and acted upon appropriately.
• Regular information was collected and reviewed to measure the quality of the service. Young people were able to give their views on the service.
• Staff were committed to improving the service they were delivering. Many staff were undertaking work to try and review and improve care for young people.

However

• The trust had high levels of staff vacancies, especially at Woodland House and Acorn Lodge although on a day to day basis they were taking the necessary steps to ensure the children and young people received the necessary care.
• Not all records at Acorn Lodge showed up-to-date care plans and risk assessments.
• Having two wards co-located in one space at Woodland House made it hard for staff to manage the ward.
• Not all staff had received regular one-to-one formal supervision.

Updated 23 October 2018

We rated it as good because:

• Staff completed a comprehensive mental and physical health assessment on each patient shortly after they were admitted. Care plans were personalised, holistic and recovery oriented, and included patients’ views and multi-disciplinary input from the ward team. Staff completed patient risk assessments promptly when patients were admitted to the ward, and put in place detailed management plans. These were updated after incidents.
• Staff interacted with patients in a positive, respectful and discreet manner, and there was a calm and relaxed atmosphere on the ward. Most patients reported that staff treated them well and described staff as friendly, caring and supportive.
• Staff were clear about the criteria for admission to the unit and actively planned for patients’ discharge from the time of admission. They worked collaboratively with community mental health teams, rehabilitation teams and local social services. Delayed discharges were monitored and escalated when necessary.
• Although there remained staff vacancies on the ward, the trust had undertaken a recruitment campaign to attract nurses with a range of different skills to work on the ward and ensure safe staffing levels. The trust had recruited learning disability nurses, physical health nurses and registered mental health nurses. Multidisciplinary staff received the specialist training they needed to provide effective care and treatment to patients. The staff team had an in-depth knowledge of the patient group. It was anticipated that the ward would be fully staffed by September 2018.
• Staff stored medicines securely and administered them in accordance with national guidelines. They recognised, reported and investigated medicines incidents, and shared learning from incidents to reduce the number of future medicines errors.
• The service-controlled infection risk well. Staff kept equipment and the premises clean. The ward was visibly clean, tidy and well maintained.
• The service treated concerns and complaints seriously, investigated them and learned lessons from the results, which were shared with staff. Patients knew how to make a complaint.
• Governance structures in the service helped ensure that learning from incidents and complaints was shared effectively with staff and information was passed from ward to trust board and vice versa. Managers maintained oversight of the quality of the service.

However:

• Although staff told us that they were receiving regular supervision, there were many gaps in records of their clinical supervision, indicating that they did not always receive the support needed in carrying out their duties effectively. This may have impacted on the quality of care provided to patients.
• Although the service had suitable premises and equipment, some areas of the ward, identified as a risk due to poor visibility, were not consistently monitored by staff to mitigate the risks to patients. Staff had not identified expired items in one of the ward’s clinic rooms, indicating that staff were not checking these regularly. It should be noted that almost all patients on this ward were informal, and would not normally be considered at high risk of suicide or self-harm.
• No patients were given keys to their bedrooms on the ward, which meant that they had to rely on staff to lock and unlock their rooms.
• There were limited opportunities for patients and their family members to give feedback about the service they received. This was a missed opportunity to involve patients and carers in making improvements to the patient experience.
• Incidents relating to the service were not always categorised accurately, to ensure that appropriate learning was shared with staff within the trust.

Updated 18 December 2020

South London and Maudsley NHS Foundation Trust provide specialist child and adolescent mental health services (CAMHS) community teams for children and young people up to the age of 18 across the boroughs of Southwark, Lewisham, Lambeth and Croydon. The trust provides a diverse range of specialist outpatient services some of which are national specialist services supporting children and young people with a wide range of disorders including autism, learning disabilities, eating disorders, self-harm, substance abuse and emotional disorders.

This inspection primarily focussed on the specialist community teams supporting children, young people and their families from the four local boroughs, crisis services, and National and Specialist services for people with complex autism associated neurodevelopmental disorders (SCAAND).

Following the last CQC inspection of this core service in January 2016, this core service was rated Goodacross all domains. However, SCAAND and centralised crisis services were not included. The current responsive focussed inspection, only includes ratings for Caring, Responsive, and Well-Led for this core service, as we did not inspect all areas of the other two domains. We used CQC’s interim methodology for monitoring services during the COVID -19 pandemic.

To fully understand the experience of people who use services, we always ask the following five questions of every service and provider:

• Is it safe?

• Is it effective?

• Is it caring?

• Is it responsive to people’s needs?

• Is it well-led?

As part of this inspection, we:

• Visited one CAMHS service office in the London borough of Lewisham, to look at 34 care records of young people currently using, or recently discharged from CAMHS services (including seven from SCAAND services, six from crisis services, and 21 from the four local borough teams).

• Had telephone conversations with 12 young people who were currently or had recently been using the local borough services.

• Had telephone conversations with 47 parents/carers of young people who were currently or had recently been using the services (38 from local borough services, and nine from SCAAND services).

• Had telephone/video conversations with 75 multidisciplinary staff (25 from local borough teams, 21 from crisis services, and 29 from SCAAND teams). These included doctors, nurses, psychologists, therapists (including psychotherapists, family, behavioural, occupational and speech and language therapists), trainees, and administrators.

• Had video conversations with 13 senior managers/directors with responsibility for

these services.

• Had telephone/video conversations with seven Special Education Needs Coordinators (SENCO workers) working in schools in the local boroughs.

The Service for Complex Autism & Associated Neurodevelopmental Disorders (SCAAND) is a national service. It is commissioned by NHS England with some Clinical Commissioning Group (CCG) contracts. Patients tend to have multiple co-morbidities. There are four clinical service ‘streams’ and a senior leadership team. Referrals are jointly screened and allocated to one of four streams. These are Neuropsychiatry, Intellectual Disabilities (IDT), Autism and Related Disorders (ARD) and the Autism and Intellectual Disabilities Intensive Intervention Team (AID-IIT).

The SLAM CAMHS Crisis Hub, a centralised team in place for approximately 18 months, includes four services. These are a Response team, Enhanced Treatment Service, Crisis Line, and CAMHS Bed Management team. They are in place to enhance the quality of crisis intervention within the boroughs of Southwark, Lambeth, Lewisham and Croydon. They provide a range of short-term community-based assessment and treatment options for up to two weeks and advice and support to parents/carers in partnership with various internal and external agencies.

We did not re-rate Safe and Effective for this core service as this was a focussed inspection which did not look at all sections within those domains. The rating of Good from the previous inspection across those two domains still applies.

• The service provided safe care. The number of children and young people on the caseload of the teams, and of individual members of staff, was not too high to prevent staff from giving each young person the time they needed. For young people who required urgent care, staff managed access well to ensure they were seen promptly. Staff assessed and managed risk well and followed good practice with respect to safeguarding.
• Staff treated patients with compassion and kindness and understood the individual needs of patients. They actively involved children, young people, families and carers in care decisions. Children, young people and parents/carers were involved in the design and delivery of the service.
• Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments that were informed by best-practice guidance and suitable to the needs of the children and young people. Staff engaged in clinical audit to evaluate the quality of care they provided.
• The teams included or had access to the full range of specialists required to meet the needs of children and young people under their care. Staff from different disciplines worked together as a team to benefit children and young people. Managers ensured that these staff received training, supervision and appraisal. The teams had effective working relationships with other relevant teams within and outside of the trust.
• Staff understood the principles underpinning capacity, competence and consent as they apply to children and young people and managed and recorded decisions relating to these well.
• The enhanced treatment service had developed an alternative model to young people being admitted to hospital, published in various professional publications. It demonstrated creative ways of working with young people, involving them in the service, and in training CAMHS staff.

• The service treated concerns and complaints seriously, investigated them and learned lessons from the results, and shared these with all staff.
• The service was well-led and the governance processes ensured that procedures relating to the work of the service ran smoothly.
• Leaders had the skills, knowledge and experience to perform their roles. Most staff said they felt respected, supported and valued, and that they had received appropriate support in adapting to new ways of working during the COVID-19 pandemic.

However:

• Some children and young people had significant waits for assessment and treatment. There were long waits for treatment of trauma, obsessive compulsive disorder, attention deficit hyperactivity disorder and for autism assessments (which had been exacerbated by COVID-19 restrictions).

• Many parents/carers told us that they had not received communication or support whilst waiting for assessment or treatment. Staff were aware of this and had taken steps to contact people on the waiting list in recent months.
• Parents/carers told us that they were not always given enough support or signposted to support available to them outside of working hours.
• There was a lack of consistency in where staff recorded information about children and young people’s care and treatment in care records. This could lead to delay in locating the most up-to-date information by a team member if needed promptly.

• Although young people said staff discussed care with them, we did not find evidence of the child or young person’s views documented in the care records.

• Some teams were struggling with ongoing staff recruitment and retention issues and insufficient funding to meet the needs of children and young people living in their area. Croydon teams in particular had experienced recent disinvestment. Some staff spoke of their frustration in having limited resources to focus on prevention and early identification of mental health issues in children and young people.

Updated 8 January 2016

We rated South London and Maudsley NHS Foundation Trust community mental health services for people with learning disabilities as outstanding because:

The service was well-resourced with experienced and skilled staff. The service supported staff to develop their knowledge and expertise. The service was linked with the Estia Centre which is a training learning and development resource for adults with learning disabilities and additional mental health needs. This enabled staff to work collaboratively with their peers to develop best practice and work in innovative and pioneering ways.

Staff undertook holistic assessments of people’s needs. They fully took people’s individual learning disabilities and communication needs into account and developed ways of involving them in planning their care and treatment. People’s dignity, independence and confidence in their skills were promoted by the way staff interacted with them and involved them in the process of planning their support.

The service worked in creative ways with people and their carers and made a positive difference to their quality of life. Staff offered people a personalised treatment plan from a wide range of possible pharmacological, psychosocial and psychological interventions. The service monitored how people responded to care and treatment.

Staff worked constructively in partnership with people’s informal carers, relatives and others in their local support network to deliver and develop joined-up care and support to people.

People and their relatives consistently told us staff were kind, polite and sensitive to their needs. Informal carers reported they had received prompt and effective support from the service which had alleviated their stress.

Updated 23 October 2018

Our overall rating for community-based mental health services for older people stayed the same. We rated it as good because:

• The leadership, governance and culture of the service actively encouraged the delivery of person-centred care. The service had capable managers at all levels with the right skills and abilities to run a service providing high-quality, compassionate, sustainable care.

• Services were very well-led and allowed staff to be creative and innovative in their approach to care and treatment. Evidence was used to develop new tools and effective services. Quality improvement initiatives and research had led to the development of new ways of working. Innovations had been shared with other health services and professionals both nationally and internationally.

• Services took account of the diverse needs of patients and carers. The memory service in Lambeth and Southwark was working towards increasing the number of black and minority ethnic people being referred to the service. Staff from the service had piloted an innovative series of sessions on dementia for children in schools as a way of raising awareness among local communities. Staff were sensitive to the needs of LGBT+ patients. Premises were accessible to people with mobility problems and staff saw patients at home when this was more appropriate.

• Staff worked actively to reduce prescriptions of anti-psychotic medicines and medicines that had an adverse effect on memory.

• Staff were compassionate, respectful and responsive to the needs of patients and carers. Feedback from patients and carers was very positive and staff were continuing to consider ways in which they could involve patients and carers in decisions about the services.

• Staff of different kinds worked together as a team to benefit patients. A full range of experienced professionals worked across the teams and were able to provide the necessary interventions to patients. Staff worked well together both within their teams and with other teams to ensure that patients received the support they needed in a timely manner. Teams referred patients to other services when this was appropriate.

• The service had enough staff with the right, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment. Staff had manageable caseloads and were able to respond promptly when an urgent assessment was needed. Work had been done to improve the waiting times for an assessment at Croydon memory service. All memory services were working hard to decrease their referral to diagnosis times, so that they could reach a six-week referral to treatment target by 2020.

• The service had made improvements to the quality of patient risk assessments since our last inspection in September 2015. Staff used a comprehensive risk assessment tool, which prompted them to cover all areas of risk in sufficient detail including how to safely manage the identified risks. Risk assessments were easily accessible to staff and stored in an appropriate place on the electronic patient record. Teams managed patient risk well. They used regular zoning meetings to identify and focus on patients at high risk.

• Staff had made improvements to the way they transported medicines and disposed of sharps. Although a few staff in one team did not always follow trust policy in respect of the disposal of clinical waste this was promptly addressed by managers.

• Similarly, improvements had been made in lone working procedures, the application of the Mental Capacity Act, compliance with safeguarding procedures and to patient waiting areas in Lambeth. Work had also taken place to improve patient crisis plans. These were now in place and patients knew who to contact in an emergency.

However:

• Whilst the trust was using technology to support mobile working in some teams this had not yet been rolled out across all the teams. Staff told us that they had to return to the office at the end of the day to complete patient care and treatment records, which was not an effective use of their time and may have had a negative impact on the quality of record keeping.’

• Whilst patient care plans identified all aspect of patients’ care, they were not particularly accessible to patients who were living to dementia. The trust was in the process of improving care plans in terms of accessibility to their patient group during the time of our inspection. Similarly, standard methods for giving feedback about the service did not take into account the particular needs of patients with dementia or offer them suitable alternatives.

• The recording of staff supervision in Lewisham older adult CMHT was inaccurate and resulted in under reporting. It was difficult for the team manager to be assured about the frequency of supervision taking place in the team without access to full records.

• Teams were not routinely discussing incidents and complaints at their business meetings as a way of learning and promoting improvements.

Updated 8 January 2016

We rated the South London and Maudsley NHS Foundation Trust wards for people with autism as outstanding because:

Staff working in the service were acknowledged experts in the assessment, care and treatment of the mental health needs of people with autism spectrum disorder. Staff worked constructively with patients to involve them in planning their care and treatment. The service had a track record of success in reducing the incidence of challenging behaviour and the severity of mental illness symptoms in patients who had very complex needs.

The approach of the service was creative. The mult-discipinary team worked effectively to ensure assessments were holistic. The team developed each patient’s care and treatment from a broad range of possible interventions. There was a focus ensuring that patients discharged from the National Autistic Unit were either prescribed no medicines at all or prescribed the least amount of medicines for their mental health needs. Staff interacted with patients in ways which enhanced their dignity, independence and confidence.

Morale was high with staff describing a positive working environment and constructive working relationships with multi-disciplinary team colleagues. Staff worked effectively with commissioners and other agencies from across the country in relation to the admission and discharge of patients.

Updated 4 August 2023

We carried out this unannounced comprehensive inspection to follow up on concerns found at our last inspection of 2019, when we rated the trust overall as requires improvement.

We inspected the three inpatient rehabilitation wards; Heather Close (24 beds), Tony Hillis Unit (15 beds) and Westways (18 beds) .

Our rating of services stayed the same. We rated them as requires improvement because:

• There was insufficient oversight of performance and quality on the three rehabilitation wards, to pick up on inconsistent blanket restrictions, and key performance indicators specific to the rehabilitation pathway.
• Care plans for patients on Heather Close and Tony Hillis Unit were not available in a format that patients could easily understand, with clear goals set to work towards developing independence skills and discharge. On Westways this issue had been addressed through the use of a ward round action plan.
• Patients gave varying reports about the meals provided on the wards particularly to meet dietary and cultural needs. There were insufficient opportunities for self catering on the wards.
• Although there were procedures in place to enable patients to develop self administration of medicines on the wards, at the time of the inspection no patients had progressed beyond the first stage of this process.
• Emergency grab bags on the wards only included one size of airway tube to enable resuscitation (although this was reviewed immediately following the inspection).
• Some staff spoke of a need for improvement in the culture between staff at Heather Close, to ensure that all staff felt valued and respected.
• The layouts on Heather Close and Westways made it difficult for patients to focus on activities held in the dining room or lounge areas.
• Staff retention and vacancies on the wards had been an issue, leading to significant use of bank (as and when) staff which impacted on the relationships developed with patients.
• Staff on the wards noted that they were sometimes under pressure to admit patients that they did not think were ready for rehabilitation, leading to longer lengths of stay.

However:

• There were improvements in the development of a clear strategy for rehabilitation across the service, and in introducing rehabilitation goals for patients to work towards.
• Each ward had a positive atmosphere and we saw good interactions between staff and patients, particularly on Tony Hillis Unit. In-reach and in-house peer support workers were making a difference to patients’ support.
• There was good involvement of relatives/carers across the wards when patients consented to this. There was effective participation of patients and relatives in ward rounds.
• There was an effective multi-disciplinary team mix on each ward and we found significant improvements in physical health support for patients.
• There was a low use of physical interventions, and reduced blanket restrictions had been put in place across the wards.
• We found improvements around the management of medicines, and clinic rooms across the wards. Patients were able to have conversations about their medicines with staff as needed and staff monitored patients’ physical health care providing support.
• On Heather Close the psychologist was piloting virtual reality headsets for patients experiencing anxiety, as well as for staff wellbeing interventions. Staff at Tony Hillis Unit continued to facilitate a group in conjunction with the forensic personality disorder community team to support patients with substance misuse problems alongside their mental health problems.
• Staff at Heather Close continued to involve patients in chairing their Care Programme Approach meetings co-producing the questions they would ask to facilitate the meeting.

How we carried out the inspection

This inspection was unannounced. It involved a three-day visit to the wards and was followed up by interviews with carers and a video call meeting with senior managers.

Before the inspection visit, we reviewed information that we held about the location.

During the inspection visit, the inspection team:

• toured the service environment
• observed how staff were caring for patients
• conducted a structured short observational framework for inspection to observe the ward culture on one ward
• observed 2 multidisciplinary handover meetings, part of a ward round, a referrals meeting and a care improvement service meeting
• observed some patient activities including a music appreciation group
• spoke with 9 patients who were using the service
• spoke with 11 relatives/carers of patients using the service
• spoke with the 2 ward managers, a practice development nurse and clinical charge nurse
• spoke with 30 other staff members across the multidisciplinary teams including consultant psychiatrists, speciality doctors, occupational therapists, clinical psychologists, activity coordinators, registered nurses, clinical support workers, a pharmacist, a peer support worker, a housekeeper, student nurses and bank (as and when) staff
• reviewed 15 patient care and treatment records
• reviewed 32 patient medication administration records
• looked at documents related to the running of the service
• spoke with the service directors for Lewisham and Croydon, and the South London Partnership programme director for the complex care pathway.

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

What people who use the service say

Patients told us that staff provided them with help, emotional support and advice when they needed it. They said that staff were sensitive to them, and gave them space when they needed to be alone. Although they said that there were often changes in staff, patients noted that staff were generally cheerful, listened to them and did not speak over them.

Patients said staff treated them well and behaved appropriately towards them knocking and waiting for an answer before entering their bedroom, to respect their privacy and dignity. They said that they were shown around the wards on admission, and given a welcome pack with information about the wards.

Patients generally felt safe on the wards, and had a primary nurse who they had regular contact with. They said that staff were available to support them, although they were often busy, and had a lot of records to complete. They said that staff involved them in making decisions about their care.

Patients and their family members told us how they had made progress since being at the service through the support and care of the staff. Most knew how to contact an advocate if they wished to, and how to make complaints or suggestions about the wards. Some patients were frustrated with the length of time they had been on a rehabilitation ward.

There were mixed reports about the quality and choices of food available on the wards. In general patients were satisfied with activities available to them on the wards. On Tony Hillis Unit, patients told us that there were few activities available at weekends.

Updated 4 August 2023

South London and Maudsley trust had 4 wards for older people with mental health problems, we visited all 4 as part of this inspection. Hayworth ward and Aubrey Lewis 1 ward mostly had patients with non-organic disorders compared with Chelsham house and Greenvale ward who had patients with organic disorders. Greenvale ward was more integrated into the community and mainly had patients with advanced dementia and patients who were on end of life care.

This was an unannounced comprehensive inspection. The last inspection of this core service was in 2017 and there was one requirement notice issued around staff completion of mandatory training, regulation 12.

We rated this service as good because:

• All wards were clean, well equipped, well furnished, well maintained and fit for purpose. The service had enough nursing and medical staff, who knew the patients and received basic training to keep patients safe from avoidable harm. The service had progressed in reducing staff vacancies.
• The service used systems and processes to safely prescribe, administer, record and store medicines. Staff regularly reviewed the effects of medications on each patient’s physical health.
• Staff assessed the physical and mental health of all patients on admission. They developed individual care plans, which they reviewed regularly through multidisciplinary discussion and updated as needed. Care plans reflected the assessed needs, were personalised, holistic and recovery-oriented, and had direct views from patients.
• Staff provided a range of care and treatment interventions suitable for the patient group and consistent with national guidance on best practice. They ensured that patients had good access to physical healthcare and supported patients to live healthier lives. Patients had access to drama therapy. On Chelsham ward patients had access to sensory machines.
• Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. Patient records showed that staff assessed and recorded capacity clearly for patients who might have impaired mental capacity.
• The service managed beds well. This meant that a bed was available when needed and that patients were not moved between wards unless this was for their benefit. Managers worked with social care teams to find appropriate community care home placements for patients with advanced care needs.
• Leaders had the skills, knowledge, and experience to perform their roles, had a good understanding of the services they managed, and were visible in the service and approachable for patients and staff.
• Staff said they felt respected, supported, and valued. They reported that the trust provided opportunities for career progression.

However:

• The ligature risk audits did not reflect all the potential ligature risks. For example, there were plastic bags and metal bins placed in the communal area bathrooms in the wards, which could pose a ligature risk. The trust had considered alternative methods for disposing of clinical waste to avoid the use of plastic bags on the ward, but this needed to be kept under review.
• Whilst the completion of mandatory training had improved, some staff still had to complete their mandatory training courses, specifically fire warden training, manual handling training, completion of national early warning scores for physical health checks and safeguarding training. The trust were aware of when staff needed to complete their training and had systems in place to remind them.
• There were still some improvements which had been identified but still needed to be made the ward environments, such as replacing the windows on Greenvale ward and providing an accessible female only bath on Aubrey Lewis 1 ward. There were plans in place for this to happen. Female patients on Hayworth ward had identified that the ward could benefit from more female toilets.
• Patient menus were not accessible or an easy read version.
• Patients did not always receive neurological observations after they had sustained a fall.

Updated 30 July 2019

We rated this service as good because:

• The service provided safe care. Staff assessed and managed risk well and followed good practice with respect to safeguarding and management of medicines. Managers investigated incidents appropriately, shared lessons learned with the wider service, and gave patients honest information and suitable support.

• Staff developed holistic, recovery-oriented care and treatment informed by a comprehensive assessment. They provided a range of treatments that were informed by best-practice guidance and suitable to the needs of the patients. Staff engaged in clinical audit to evaluate the quality of care they provided.

• The teams included or had access to the full range of specialists required to meet the needs of patients. Staff worked well together as a multidisciplinary team and with relevant services outside the organisation. Staff directed patients to other services when appropriate and, if required, supported them to access services, such as local children’s centres.

• Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.

• Staff treated patients with compassion and kindness and respected their privacy and dignity. They understood the complex individual needs of patients preparing for motherhood, and as new mothers, and supported them to manage their mental health, and develop parenting skills. They actively involved patients and families and carers in care decisions.

• The service was easy to access. Staff assessed and treated patients who required urgent care promptly. The criteria for referral to the service did not exclude patients who would have benefitted from care. Staff followed up patients who missed appointments.

• The service was well-led, and governance processes ensured that procedures relating to the work of the service ran smoothly. Staff were encouraged to be involved in research and innovative practices.

However:

• Staffing vacancies and poor staff retention were having an impact on the consistency of support for patients and led to increased stress on the remaining staff. However, recruitment was taking place specifically for the service and they were also using regular temporary staff where possible. One community perinatal team had waiting times for non-urgent appointments to see a doctor of over four weeks although urgent appointments were available.

• Although it did not compromise safety because staff mitigated the risks, the physical environment of the mother and baby unit was not ideally suited to support high quality care. There was a lack of ensuite facilities, the nursery was too small, the garden space was not safe for use by all patients, and there was not enough space for patients to meet with visitors. The trust had a long-term estate plan but these shortfalls could not be addressed quickly. In the Southwark, Lambeth and Lewisham perinatal community teams, there were insufficient rooms available to meet with patients. Whilst appointments had not been cancelled, staff had to plan carefully to ensure everyone was seen.

• There were long waits for psychological therapies in the community perinatal teams, which did not always meet the recommended timeframes of assessing patients within two weeks and providing treatment within four weeks. In two boroughs patients were waiting up to 16 weeks. More clinical psychologists were being recruited and assistant psychologists were offering more group work in the interim period.

• Whilst average numbers of staff receiving regular supervision across the services was over 80% there were a few areas where this had gone lower. For example, in March 2019 this had fallen to 67% in the MBU. However, all staff felt well supported by their managers and had regular access to reflective practice. The MBU manager was aware of levels of supervision and was working to ensure they were consistently within the trust target.