South London and Maudsley NHS Foundation Trust

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

This means we looked for evidence that the service met people’s needs.

At our last inspection we rated this key question requires improvement. At this inspection the rating has remained requires improvement. We found 2 breaches of the regulations in relation to timely access to services and delays to assessments under the Mental Health Act. These breaches limit the key question rating to requires improvement.

Requires improvement: This meant people’s needs were not always met by staff within the service. Staff did not always make sure people who used services were assessed in a timely way, including when they needed assessment under the Mental Health Act.

However, staff mostly understood the health and care needs of people who used services. Care and treatment met the diverse needs of communities. People were encouraged to give feedback, which staff acted upon and used to deliver improvements.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service mostly ensured people were at the centre of their care and treatment choices and decided, in partnership with them, how to respond to any relevant changes in their needs.

Not all care plans we reviewed were person-centred and individualised. They did not always reflect the goals of people who used services. We saw the use of generic statements in some care plans we reviewed, with the person’s voice not reflected. Staff did not always review and update them each year or when people’s needs and circumstances changed.

However, during our inspection we saw examples of how staff in the service provided person-centred care. For example, we saw staff playing guitar with someone who used services during their meeting to improve their engagement in the session.

Staff responded flexibly to ensure care and treatment was delivered in line with people’s choices. Staff gave the example of transferring someone to another team to ensure they got a care co-ordinator they were willing to engage with. People who used services told us their views had been taken into account about medicines they were prescribed. One person told us staff had respected their wishes to stay on depot injections rather than change to tablets.

Staff spoke positively about supporting people to achieve their individual recovery goals and were able to give examples how of people had achieved them. For example, one staff member talked about supporting an individual to keep a positivity journal which had helped their recovery.

Staff gave people who used services information on how to access further sources of information such as advocacy services and voluntary sector agencies.

The service understood the diverse health and care needs of people and their local communities, so care was joined-up, flexible and supported choice and continuity.

Staff worked in a collaborative way to provide continuity of care and treatment when people who used services were referred to another team. Staff worked with other teams such as the home treatment team to ensure joint visits and assessments were carried out when someone needed additional support due to a mental health crisis.

Managers in Southwark directorate met daily with colleagues in psychiatric liaison and bed management meetings to ensure the care and treatment of people transferring to community mental health teams was co-ordinated.

Some teams had staff to co-ordinate the discharge of people who required less intensive support. They worked with colleagues in primary care and low intensity treatment teams to ensure they had the information they required to support and treat the person.

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

The service complied with the Accessible Information Standard. The Accessible Information Standard is a legal requirement for organisations providing NHS care to ensure that people with disabilities or sensory losses receive information and communication support in a way they can access and understand. The trust website met accessibility standards and information could be easily accessed by making it larger or changing colours and fonts. It included a text to speech feature for people who may not be able to read the information. It also had a jargon buster page which explained terms used within the NHS and service in plain English.

Staff told us they were able to access translation and interpretation services for people who spoke languages other than English.

The service provided information for people who used services in waiting and reception areas. In the waiting area in Marina House, Southwark we saw information leaflets and posters about physical health, other support services available, Healthwatch, employment support and the recovery college. Information was displayed in languages other than English. People who used services received information leaflets about their medicines. These were available in different languages.

Information governance systems ensured the confidentiality of care records. Staff accessed electronic patient records securely, using passwords, and logged out when not using them to prevent any unauthorised access.

The service had systems for people to share feedback and ideas or raise complaints about their care, treatment and support. It involved them in decisions about their care and told them what had changed as a result.

The service provided opportunities for co-production and co-design, enabling people who used services to have meaningful involvement in service development and improvement. The service user committee met monthly, and we saw people who used services had been involved in the development of the new neighbourhood team model in Lewisham. The service had a service user, carer and community engagement plan for their care transformation programme. The care transformation programme aimed to move from consultation and co-design to co-production; with people who used services, carers, staff and other members of the community working alongside each other to transform services.

The service had introduced a new way to hear from people who used services and their carers through the stories project. This project used trained ‘story collectors’ to collect experiences and stories through informal conversations with people who used services.

Staff provided opportunities for carers and families to give feedback on services. In Lewisham, staff facilitated a monthly carers support group alongside previous carers. They had produced a report in February 2025 called ‘LEIS Listens’ which summarised feedback from 23 carers of people who used the early intervention in psychosis team. This included recommendations to improve services.

The psychology team in Southwark offered therapeutic support for carers and families. This was group work based on an approach that usednetwork meetingsto address mental health crises, particularly psychosis, by including the person's family and social network in treatment decisions and discussions.

The systems used to gain feedback from people who used services were not always effective. Some staff told us it was difficult to get feedback from people who used services. People who used services were asked to fill in a questionnaire about their experience, however, staff told us they got low numbers of returns. People we spoke with on inspection told us they were not always asked about their views on their care and treatment.

Most people we spoke with who used services confirmed they knew how to complain or raise concerns, including those who said they had no reason to complain. However, 3 people told us they would be worried about making a complaint in case it impacted on their care and treatment.

The service kept a formal record of all complaints. In the last 12 months there were 199 complaints about the service. The majority (163) related to complaints about care and treatment. The service investigated complaints. We reviewed the last 5 complaints and saw 3 were not upheld, 1 was partially upheld and 1 was upheld. Between July 2024 and June 2025, 10 complaints were upheld by the Ombudsman and 1 complaint was referred to them.

The governance team kept managers and staff informed of complaints made and circulated a tracker which tracked open complaints and their progress.

Staff were supported to deal with vexatious complaints and gave an example of being supported by the trust to put in place a plan to manage this. A vexatious complaint isone that is pursued, regardless of its merits, solely to harass, annoy or subdue somebody.

Changes were made following themes identified in complaints. For example, in Croydon directorate there had been a theme around waiting for diagnosis and other services such as autism services. The service had introduced integrated neurodevelopmental practitioners in the teams who could carry out autism diagnosis assessmentsand offer 6 to 8 sessions of post diagnosis education and support.

The service did not make sure that people could access the care, support and treatment they needed when they needed it.

The service did not always provide treatment in a timely way. At our last inspection we found the service did not always meet their target for assessing non-urgent referrals within 28 days. The service still did not always meet targets for the length of time between referral and first contact from the service. The trust’s integrated quality and performance report for May 2025 showed Lambeth was the lowest performing directorate for percentage of referrals to first contact seen within 28 days. Compliance was 80% against a target of 95%. Following our inspection, the trust provided an updated integrated quality and performance report. This showed in August 2025 compliance with first contact within 28 days was 95% on Croydon, 91% on Lewisham, 94% in Southwark and 76% in Lambeth.

At our last inspection we told the service it must ensure people who required an assessment under the Mental Health Act (MHA) were assessed without undue delay. There were still delays in carrying out MHA assessments for people who used services.There was an average of 4 cancellations of MHA assessments each month, across the service. There were 25 cancellations in the last 6 months, with 16 of those due to a lack of inpatient bed capacity.

Twelve people in Southwark directorate were waiting for an MHA assessment at the time of our inspection. Of these, the shortest wait was 18 days and the longest was 164 days. There had been 3 attempts at conducting an assessment for the person waiting 164 days but they were not at home and a delay to the assessment in June 2025 was as there was no bed available.

Twelve people in Croydon directorate were waiting for an MHA assessment, where the shortest wait was 1 day and the longest was 30 days.The longest wait was due to an error between 2 external partners and the average wait for an assessment was 2 weeks.

Five people in Lewisham directorate were waiting for an MHA assessment, where the shortest wait was 5 days and the longest was 69 days. For the delay of 69 days, the service had made 2 attempts to conduct an assessment, but the person was not at home. The next longest delay was 21 days, which was due to lack of police availability.

Following our inspection, we told leaders the service should make improvements to ensure people received timely assessments under the MHA. The service told us they had reviewed the cases of people waiting for an assessment under the MHA and they had all continued to receive support and care whilst they waited for an assessment.

The service told us it had a number of processes to support assessments under the MHA to take place and oversee bed management. Managers met daily to review all cancellations, and the number of assessments needed. This included daily bed management huddles with beds booked 24-hours in advance for people undergoing assessment under the MHA. The service had weekly meetings with the police and AMPH service. Staff from home treatment teams worked with the CMHTs to review people who were waiting for a MHA assessment. The trust monitored MHA assessment cancellations through the integrated quality and performance committee chaired by the Chief Medical Officer, Chief Nurse and Chief Operating Officer.

The service said it had taken a comprehensive review of our concerns to ensure the safety of people using services was not compromised and submitted additional information. This evidence showed that 16 out of 42 people went on to be admitted to an inpatient bed or health-based place of safety. In 29 cases there was no evidence to show people had their assessment cancelled due to successful intervention by community teams. Therefore, systems and processes were not always effective in reducing delays in carrying out assessments under the MHA. We have told the service it must make improvements to ensure people receive timely assessments under the MHA when required. Following this, the service provided information to show the number of cancelled MHA assessments had fallen since our inspection, including those cancelled due to bed capacity.

The service did not always act in a timely manner to assess and respond to the risks associated with people who used services experiencing deterioration in their mental health. We reviewed the number of people waiting for assessment by the Lambeth single point of access team. There were 7 people who had waited over 100 days for assessment and an additional 52 people who had waited over 90 days. We raised these concerns with leaders following our inspection. They took immediate action to ensure all people on the waiting list would be reviewed by the end of June 2025.

There were delays for people who used services to access psychology. In the Lewisham Early Intervention in Psychosis Team there was a waiting list of 8 months for psychology. Managers told us this was due to vacancies within the team which had now been filled so they expected the waiting list would reduce. Staff in Southwark told us there were lengthy waits for psychology input, particularly cognitive behavioural therapy and dialectical behaviour therapy.

However, the service had systems and processes to ensure effective discharges from the service. Managers in the Lewisham Early Intervention in Psychosis team were working with people who used services to identify barriers to discharge and support them to transition to primary care or other services. Staff discussed all planned discharges from the service at multidisciplinary team meetings.

Waiting and reception areas were wheelchair accessible.

Staff and leaders actively listened to information about people who were most likely to experience inequality in experience or outcomes and tailored their care, support and treatment in response to this.

Staff were trained in equality, diversity, inclusion and human rights. In Croydon directorate 93% of staff had completed training, in Lambeth 91%, in Lewisham 93% and in Southwark 96%. Staff we spoke with showed an understanding of the diverse needs of the communities people lived in. They worked with voluntary, community and social enterprise groups to ensure people who used services could access support that was culturally appropriate.

In Croydon directorate, staff could access weekly sessions provided by a local forum which focused on culturally sensitive support.

Staff gave examples of work to support people from ethnic minority groups. The service had a dedicated practitioner who worked alongside the local refugee network to ensure refugees were able to access services. Staff gave examples of carrying out assessments in community venues such as homeless drop-in centres and bridge clubs to ensure they reached and engaged with people who might find it difficult to attend trust venues and premises.

Managers monitored ethnicity data of people who used services so they could ensure care and treatment did not put people from ethnic minority groups at a disadvantage. The service used an online dashboard, aligned with care records that recorded and monitored ethnicity data for people who used services. The service provided information showing 100% completion of ethnicity data in care records. The service monitored outcomes for people from ethnic minority backgrounds. Data provided showed compliance with the target for waiting time target by ethnicity varied across the directorates, with Southwark directorate demonstrating the most consistent and equitable outcomes. However, in Lambeth directorate there was more variation in wait time for people from ethnic minority backgrounds. Following our inspection, the service provided board papers which showed there had been improvements in waiting times for CMHT across all ethnicities, though data was not available for Lewisham directorate. We saw this was monitored and reported to the board as part of the integrated equalities action plan annual report. We reviewed the report presented to the board in July 2024 and saw reducing inequity in waiting times for community services was a key service delivery objective and built into ongoing community transformation work.

The service had undertaken equality impact assessments of their policies and procedures to ensure they did not place vulnerable people or people with protected characteristics at a disadvantage. Managers could access equality impact assessment templates and guidance to support them when reviewing or developing policies and procedures. Trust guidance for development and management of policies included templates for equality analysis, equality action plans and Human Rights Act impact assessments, which managers used when developing policies.

The trust had assessed itself against NHS England’s patient and carer race equality framework (PCREF). PCREF is a mandatory framework for trusts to follow to become actively anti-racist organisations by ensuring that they are responsible for co-producing and implementing concrete actions to reduce racial inequalities within their services. The trust worked with local groups representing people from ethnic minority backgrounds to implement PCREF through partnership teams and independent advisor groups in each borough. The trust ensured when there were changes to services or service developments, they had a service user or carer representative from an ethnic minority background, a community representative from an ethnic minority background and a trust staff representative involved in decision making processes to ensure they got all views and perspectives. The trust had a PCREF action plan for 2025-26, which was embedded within governance and accountability structures.

People were supported to plan for important life changes, so they could have enough time to make informed decisions about their future.

People who used services were supported to plan their future care while they had the capacity to do so. We saw a person’s capacity was considered at initial assessment and throughout their time under the care of the team and was recorded in care records. Lewisham directorate employed a crisis plus practitioner. They supported people who had frequent contact with crisis services to develop anticipatory management plans whilst they were stable under community services. These plans set out what care, treatment and support a person wanted if they were to experience a mental health crisis in future.

People who used services told us staff helped them plan what to do if their condition deteriorated and ensured they had contact details to use if this happened.

Staff ensured relevant healthcare professionals and other relevant bodies were involved in planning the care and treatment of people with complex needs. For example, we saw examples of joint work between community teams and assertive outreach and crisis teams to ensure individuals received appropriate care and treatment.