- SERVICE PROVIDER
South London and Maudsley NHS Foundation Trust
This is an organisation that runs the health and social care services we inspect
Report from 5 February 2026 assessment
Contents
Ratings - Mental health crisis services and health-based places of safety
Our view of the service
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.
People's experience of this service
We spoke to 14 people who used services and 7 carers or family members.
Some people who used home treatment team services said staff were respectful, supportive, responded quickly to queries, were flexible with appointments and they felt listened to. One person told us “anything I needed, they accommodated”.
We observed kind and compassionate care during observations of crisis calls and face to face assessments. People who used services gave examples of being referred to different teams or providers to help with advice for eating disorders and substance misuse concerns.
However, patients and people who used services told us they were often seen by different people and there was poor communication from the service, with a lack of regular discussions with people about their treatment plan. Two people told us they would have appreciated being able to use the home treatment team (HTT) for a longer time before being discharged.
Feedback from Healthwatch in Lewisham from May 2024 to June 2025 included positive themes of friendly and compassionate staff, medication reviews and requests for support with regular medication. Complaint themes from people who used services included delayed crisis support, feeling overwhelmed by HTT visits, issues with medication and a breakdown in communication during discharge or crisis planning.