South London and Maudsley NHS Foundation Trust

Ratings - Well-led

• Well-led Our assessments of NHS trusts now focus on leadership. We no longer rate trusts overall for their safety, effectiveness and responsiveness or how caring they are. We do still publish those ratings for the services they provide.

  Requires improvement

Our view of the service

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.

People's experience of this service

During our assessments of acute wards for adults of working age and psychiatric intensive care units, community health services for working age adults, crisis and health-based place of safety and forensic mental health services we spoke with 156 people using the service, their relatives or carers. We received mixed feedback from service users and carers about the care they received. Some spoke highly of staff and the care they received. However, some raised concerns about access and delays to treatment.

The 2024 NHS community mental health survey showed the trust scored about the same to most other trusts in all areas except psychological therapies and respect, dignity and compassion. The trust scored worse than other trusts in relation to psychological therapies, including the privacy during therapy and feeling they had enough privacy to talk comfortably. They scored slightly worse than other trusts in relation to respect, dignity and compassion and being treated with care and compassion by the NHS mental health team

A review of service user complaints highlighted delays in the trust responding. At the point of the well led assessment the trust had complaints which were overdue. Our review of complaints also noted that whilst complaints were mostly dealt with effectively, there was some inconsistency in the quality of the response. However, the trust was aware of this and had introduced new processes designed to improve the consistency in this area. The trust had also coproduced new complaints posters for clinical areas to support and encourage service users to make complaints.

Co-production with people who use services and carers had become an area of focus for the trust. A good example of this was the new posters recently distributed across the trust. Another good example was the Secure Settings Service User Carer Advisory Group (SUCAG) which was a monthly hybrid forum co-led by a lived experience practitioner and a patient and public involvement lead. This meeting supported inpatients, community service users, carers, and staff to come together to shape service provision through meaningful co-production.

Feedback from local Healthwatch’s on people’s experiences was mixed. There was some negative feedback about access to services and delays; however, once people were in receipt of services the feedback was largely positive.

The trust gathered feedback from people who used their service through a friends and family test (FFT). The FFT asks people about their overall experience of services they have used and offers a range of responses. In 2024/2 the trust received 4,800 responses to the friends and family test and 79% gave a positive response. This was below the 95% target and a decline from 85% in 2021-22