South London and Maudsley NHS Foundation Trust

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

This means we looked for evidence that people were protected from abuse and avoidable harm.

At our last inspection we rated this key question requires improvement. At this inspection the rating has remained requires improvement. We found 3 breaches of the regulations. It did not assess and respond to risk through management of waiting lists and effective risk management meetings. Staff did not always complete risk management and safety plans. The service did not always ensure it provided environments that were fit for purpose.

The service did not always establish and maintain safe systems of care, in which safety was managed or monitored. The service did not always work with people to understand and manage risks so that care met their needs in a safe and supportive way. The service detected but did not always control potential risks in the care environment, including infection prevention and control risks. They did not consistently make sure facilities supported the delivery of safe care. The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

However, the service operated effective systems and processes to make sure people were protected against abuse and neglect. Safety events were mostly investigated and reported, and lessons learned to identify and embed good practice. The service mostly ensured there were enough staff to provide care that met people’s needs.

This service scored 44 (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 did not always maintain a proactive and positive culture of safety based on openness and honesty. Safety events were not always investigated and reported thoroughly, and lessons not always learned to identify and embed good practices.

The service reported 9 serious incidents in the last 12 months which were still being investigated across the relevant directorates. This included:

• Lambeth directorate reported 4 serious incidents, 2 alleged homicides and 1 safeguarding,
• Southwark directorate reported 2 serious incidents, 1 probable suicide, and 1 fire in flat,
• Lewisham directorate reported 2 serious incidents, both alleged homicides,
• Croydon directorate reported 1 serious incident, and an alleged homicide.

However, during our onsite inspection, managers in Lewisham told us there were 7 incidents of harm in the last 12 months, 5 deaths, 1 incident of self-harm and 1 of harm to others.

The community mental health services for working age adults provided data showing there were 308 incidents reported in the last 3 months, across all directorates. The largest number of incidents related to medicines.

The trust defined a serious incident as an incident where a patient safety incident investigation (PSII) was mandatory. This included homicides, inpatient deaths, deaths in which there were safeguarding concerns and maternal and child deaths. All deaths, except homicides, on another person had a mortality review.

The trust provided a PSII for 1 incident which showed there were no recommendations or safety actions. The PSIIs for other incidents were not completed at the time of our inspection. The service told us all incidents were reviewed in line with trust safety governance processes to determine the most appropriate and proportionate learning response under the Patient Safety Incident Response Framework (PSIRF). PSIRF is the NHS’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents for the purpose of learning and improving patient safety. For some incidents which did not progress to a PSII the service carried other learning exercises such as Fact Finders (FF), After Action Reviews (AARs) and multidisciplinary team (MDT) reviews.

We reviewed the presentation to the patient safety committee for 4 AARs relevant to the service conducted in the last 12 months. We saw key findings were presented and lessons learned identified.

Staff completed level 1 essentials for patient safety training, and clinical staff completed additional level 2 access to practice training. Compliance with level 1 training was over 95% for community teams.

Duty of candour is a regulatory duty that relates to openness and transparency and requires providers of health and social care services to notify patients (or other relevant persons) of certain ‘notifiable safety incidents’ and provide reasonable support to that person. We reviewed 5 duty of candour letters sent between April and August 2024. We saw they contained an apology and offered sincere condolences. The letters invited families and carer to take part in the incident review process and signposted them to further resources. Staff we spoke to understood the duty of candour and incident records showed they recorded when this was required in the online incident report system.

The service told us they were working with the National Confidential Inquiry into Suicide and Safety in Mental Health regarding culture of care and promoting a "personalised approach to risk". This approach emphasised moving away from risk categorisation and scoring towards understanding individual needs and tailoring support accordingly, in line with recent NHS England guidance. This work started in April 2025 with an expected end date of March 2026. Leaders in Croydon directorate were part of the Southwest London Suicide and Self-harm Prevention steering group and had secured funding from South West London Integrated Care Board (ICB) to take forward suicide prevention priorities.

Learning from deaths was not always implemented across the whole service. For example, in response to a Prevention of Future Deaths report for Southwark directorate in May 2024, the trust stated that from June 2024 they would make changes to the audit of risk assessments to ensure quality and accuracy. The service piloted an internal assurance process and the outcome of the pilot shared across directorates. However, during our inspection we found issues with the quality of risk assessments in other directorates, and they were not always completed or up to date.

The trust held quarterly mortality review panels. We reviewed the minutes of the panels held in January and April 2025. We saw in January 2025 some learning from incidents was presented by directorate governance leads and each directorate presented a quarterly mortality report. The service planned for each directorate to allocate mortality reviews to consultants as part of consultant job plans. The trust had clear criteria for completion of a full structured judgement review following a death in line with the ‘Learning from Death’ framework. A structured judgement review is a process toeffectively review care received by patients who have died.

Some staff told us about changes made as a result of learning from incidents. For example, in Lewisham Early Intervention Team they had an incident where gaps in care were noted when the person transferred care from another service. The team had changed the process so that when someone was transferred from another service, they were reviewed 3 times a week in the multidisciplinary meeting. The service facilitated lessons learnt events for staff with presentations from external partners such a presentation by the suicide reduction manager for a rail company in April 2025.

Directorate leaders met daily to review any incidents or deaths in the previous 24 hours. They provided a learning lessons report every 3 months to the quality committee. We reviewed the learning lessons reports for the last 6 months. We saw the report covered an overview of the number of incidents for the trust and the main category of incidents, learning from deaths and a summary of key learning. The trust issued ‘Blue Light’ bulletins to staff to highlight learning from incidents which would change practice, both internal and external.

Though the service had mechanisms to share learning from incidents external to the team or service with staff, during our inspection we saw themes from patient safety incidents had not always been addressed. For example, the minutes of the mortality review panel for April 2025 showed there were 3 recurring themes from patient safety incidents including maintaining clarity of documentation and ensuring learning in relation to immediate and basic life support was maintained. During our inspection we found documentation was of poor quality, incomplete and not up to date. We found mandatory training compliance for basic life support was below the trust target in Lambeth and Southwark directorates, with compliance in Lambeth at 69%, and Southwark at 74%.

Staff we spoke to knew the importance of incident reporting and told us they felt supported to report incidents. The trust provided guidance to staff on PSIRF through the Patient Safety Incident Reporting and Management Policy. This was supported by a Patient Safety Incident Response Plan (PSIRP). The policy contained flow charts to guide staff on how to report an incident and immediate actions to take.

Staff used an ‘after action review’ tool following a serious incident to identify any immediate learning and if a fuller patient safety incident investigation was needed. They were supported by team leaders and the governance team to complete these. The service, where possible, involved relevant partners in after action reviews. However, some staff told us it was difficult to ensure all the relevant teams contributed to after action reviews.

Staff told us they were debriefed and supported following a serious incident. They had internal debrief, a team meeting discussion, and support from the trust-wide crisis intervention support service who offered formal debriefing.

The service told us there were no never events in the last 12 months. Never events are serious patient safety incidents that should not happen if healthcare providers follow national guidance on how to prevent them.

The service did not always establish and maintain safe systems of care, in which safety was managed or monitored. The service’s approach to identifying and managing risk was not always effective and did not always keep people safe.

There was no clear oversight of risk for people who were on the waiting list for the Single Point of Access (SPA) team in Lambeth. During our inspection we saw there were 596 people on the waiting list, of which 160 were urgent referrals. There were 347 people who had waited more than 29 days and 7 who had waited over 100 days. We reviewed 6 care records, specific to this service, and saw errors in the classification of service users, lack of clear records and lack of rationale for decisions within the electronic records system.

The service did not operate a robust process to clinically review people on the SPA team waiting list. We reviewed the care records for 4 people who used this service and found no evidence of clinical discussion or review. Systems did not provide staff with the information needed to monitor people on the waiting list, to assess any changes in presentation. The service had a spreadsheet to track contacts made and by whom, which was accessible to all staff but there was no formal process in place for its use.

Following our inspection we raised these concerns with leaders. They provided an action plan which addressed the concerns raised. They took immediate action to implement daily clinical risk screening by senior clinicians and screening of all urgent referrals to ensure there was no harm or risk of harm for people waiting for services.

We requested the minutes of the last 3 meetings that reviewed risks for people who used services. The service told us ‘individual patient risk is discussed in community team zoning meetings with outcomes directly placed in individual patient records’.

The zoning meeting was a daily meeting in each team where staff discussed risks for individuals. The frequency someone was discussed in the zoning meeting was based on a red, amber and green risk rating system, allocated to each person by their clinician.

A rating of red was the highest risk and meant the person was discussed daily in the zoning meeting. The trust clinical risk assessment and management of harm policy gave staff example criteria for the ratings. For example, it was suggested all people who used services who were currently an inpatient were rated red.

We attended the zoning meeting at Lewisham Neighbourhood 1 community mental health team (CMHT). We reviewed the zoning tab in the care records of 3 people who had been discussed in zoning meetings that week and none had an action plan recorded or detail of discussion of risks. This included someone who was discussed as they were an inpatient but there was no record of the detail of the discussion or any related actions. We observed the zoning meeting at the early intervention in psychosis (LEO) team in Lambeth. Despite the high-risk presentation of some people, the discussion was limited.

However, in Lewisham Early Intervention in Psychosis team staff recorded outcomes of discussions in zoning meetings in a spreadsheet that could be accessed by all staff. This also tracked any people who used services who were currently an inpatient or residing in prison. This meant staff on duty had quick access to relevant information about people who might contact them and the team leader was able to monitor discussions and actions. We did not find this positive practice replicated in other teams.

We requested the trust’s policy, process and any audits in relation to the use of Right Care, Right Person. Right Care, Right Person is an agreement between policing, health and other relevant partners that sets out the principles around the Right Care, Right Person approach which aims to ensure that individuals in mental health crisis are seen by the right professional. However, the trust did not provide this information. The trust did send three policies from June 2024 which had been created to support the implementation of Right Care, Right Person and the trust told us that leaders from each directorate met with police monthly and incidents were reviewed at the monthly police liaison group and trust leaders met police quarterly at the police interface group.

Staff did not have access to an up to date policy to follow for people that did not attend their appointments. The policy was due to be reviewed in September 2019. The service told us the policy was being reviewed as part of wider multidisciplinary, multiagency work looking at risk management protocols and approaches, including the new risk assessment work, and linking with the community transformation programme. The service did not provide details or timelines for this work. We requested but the service did not provide any audits to show they monitored the number of people who used services who did not attend appointments.

Some staff told us there was pressure to discharge people who used services to ensure caseloads were manageable and address demand. They felt that some discharges were not appropriate. However, the service had processes to monitor inpatient readmission rates to ensure discharges were clinically appropriate. Information provided by the service showed the trust readmission rate was in line with the national average. Directorate managers monitored re-referrals into CMHTs. Information provided by the trust showed in Southwark directorate 23% of people discharged were re-referred between June 2024 and June 2025 and in Lewisham this was 6%.

However, managers worked with partners and communities to plan care and support to ensure continuity. For example, in Croydon staff attended a monthly primary care/voluntary services interface meeting that included primary and GP link workers, Talking Therapies services and third sector partners. Information on high risk or complex cases was shared with other services at the Croydon Risk and Vulnerability Management Panel which included the local authority, police, health services, housing and commissioners. Leaders in Croydon, Lambeth and Southwark attended monthly ‘high intensity user forums’ with system partners.

Managers in Lewisham attended the daily emergency department huddle so they were aware of support needed for people who used services who presented to the accident and emergency department. They also attended the weekly inpatient bed management meeting to facilitate early discharge planning.

The service had a number of shared care agreements with primary care providers for mental health practitioners based within GP surgeries in in Southwark, Lewisham, Lambeth and Croydon.

Primary care mental health teams in Lewisham were able to work with people who used services for 4 to 12 weeks to provide interventions that meant they would not need referral to community mental health teams. They also acted as a point of referral into the community teams where required. Referrals to teams were discussed in weekly referral meetings.

In Lewisham staff reviewed all people who used services who were on a community treatment order (CTO) in the weekly multidisciplinary team meeting.

The service worked with people to understand what being safe meant to them as well as with partners on the best way to achieve this. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect, and made sure they shared concerns quickly and appropriately.

The service operated effective systems and processes to make sure people were protected against abuse and neglect.

Staff were trained in safeguarding. Safeguarding training compliance was above the trust target of 85% for safeguarding adults levels 1 and 2 and safeguarding children levels 1 and 2.

The trust had up to policies on safeguarding adults and children and Prevent. Prevent is the UK’s counter terrorism strategy to safeguard people and communities from the threat of terrorism.

Managers told us they had made improvements to ensure all safeguarding cases raised were tracked and an outcome recorded. There was a trust-wide dashboard for managers to monitor the number of safeguarding concerns raised, referrals made and if they were waiting for a local authority decision. Managers attended a fortnightly governance meeting where safeguarding referrals were discussed.

Most staff knew how to make a safeguarding alert. However, the process for making a safeguarding alert through trust systems and the local authority system was not aligned. Managers told us not all staff were aware they needed to make a safeguarding referral through the local authority portal. However, they had processes in place to monitor safeguarding concerns made on trust systems and cross-reference with the local authority tracker weekly to ensure safeguarding referrals were not missed.

Staff were able to give examples of safeguarding alerts they had raised such as when they thought a child was at risk of harm.

Staff could give examples of how to protect people who used services from harassment and discrimination, including those with protected characteristics under the Equality Act, such as understanding different cultures and using interpreters. Staff gave an example of working with a local food bank to ensure a person who used services could get halal food.

The service did not always work with people to understand and manage risks to ensure they met their needs in a way that was safe and supportive and enabled them to do the things that mattered to them.

Risk assessments and crisis management/safety plans were not current, not reviewed and in many cases not relevant to individual care needs. Some people who used services did not have risk assessments or crisis management plans in place. We reviewed 20 care records and 10 did not have up to date risk assessments and/or risk management plans. Of 20 care records we reviewed, 10 did not have up to date care plans.

Audits of care plan and risk assessment completion and quality between April 2024 and June 2025 showed a wide variation between each team, with the highest performing team, Lewisham Enhanced Recovery team achieving 95% compliance in the audit. Though 30 out of 39 teams had compliance above 70% some teams had poor compliance with care plan and risk assessment completion and quality. Croydon Early Intervention Service had compliance of 53%, Croydon South locality team 47% and Lewisham Community Mental Health Neighbourhood 1 team 38%.

People who used services were not always aware of being involved in safety plans or risk assessments. There was a lack of service user voice and frequent use of generic statements. We spoke to 12 people who used services and 7 carers during our onsite inspection. Twelve people told us they had not been involved in assessing their risks, or the risks to their family member. The impact on the experience for people who used services was evidenced in the 2024 community mental health survey. In the survey some people who used services reported good practices. The service’s internal audit of people’s views of being involved in decisions about care and treatment for April to June 2025 showed 64% of people definitely agreed they were. However, in the 2024 community mental health survey most people reported negative experiences and a lack of person-centred care. Some people who reported negative experiences wanted more input from care co-ordinators and more help managing other areas of their life, such as finances and housing. People sometimes felt unsupported with their needs and did not feel the service was there to help them.

There were significant gaps in crisis management and safety plans, including missing plans for people who used services who were on community treatment orders (CTO). The service reported 2 incidents since January 2025 which involved a potential breach of a CTO as the person was non-compliant with medicine. We reviewed 20 care records and 11 did not have up to date crisis management or safety plans. During our inspection, we reviewed 2 care records in Lewisham Neighbourhood 1 CMHT, where staff had not used alerts in the electronic patient record for people who had significant risk issues. However, following our inspection the trust provided evidence of 9 records where they had been used.

We raised the issue of gaps in care records during our inspection. Following our inspection, the service told us they would review these care records to ensure there was no harm caused to people who used services.

The service detected but did not always control potential risks in the care environment. They did not consistently make sure facilities supported the delivery of safe care.

We saw environments which were cramped, hot and not always fit for purpose. At Lewisham neighbourhood 1 CMHT and Lewisham early intervention team, patient waiting areas were small and cramped. At Lewisham neighbourhood 1 CMHT the impact of building work next to the building meant rooms were dusty, hot and very noisy including consulting rooms. The service carried out an environmental risk assessment of the Lewisham neighbourhood 1 CMHT premises in June 2025. This identified some measures to address issues with ventilation and temperature in the building such as use of portable fans during warmer periods. However, we saw on inspection this did not fully mitigate the issues caused by the impact of building work. Following our inspection the service confirmed the building work had been completed and had only lasted for 2 weeks.

At the North Focused Support Team base the windows in staff offices did not have window restrictors. This meant they could be opened widely posing a risk to the safety of staff from potential falls and a security risk. The building was hot with no air conditioning meaning staff frequently kept windows open. We reviewed the environmental risk assessment and this risk was not identified, as outlined as good practice by the Health and Safety Executive.

In the Lewisham early intervention team base staff could not hold depot clinics or carry out full physical health checks as they were not allowed to have any sharps in the building. Staff told us this was due to the building being leased from the council. Following our inspection the service provided information showing mitigating actions had been taken to hold physical health checks and depot medicine clinics at other trust premises. They service was also reviewing plans to provide a clinic room onsite.

At bases we visited in Lewisham and Southwark staff reported difficulties with room space which impacted the number of interventions they could offer. Several staff told us that the physical environment and lack of space impacted on the experience of people who used services and the range of interventions they could offer. Psychology staff told us they could not always fulfil clinical treatment plans as they could not ensure they had a suitable room. Following our inspection, the service confirmed only 2 incidents were raised between January 2024 and October 2025 about the lack of adequate clinical environments. The service carried out an estates exercise on use of office and clinical space in bases and work was ongoing on space utilisation to ensure premises met the needs of people using services and staff.

At the North Focused Support Team base the main staff entrance was a side door which was also the fire exit. The building did not have clear signage that it was a mental health living well centre outside. Risks related to the external environment were recorded on the environmental risk assessment, however measures to prevent risk of injury were not always effective. For example, the risk assessment stated the external area should be kept clean and tidy, but this was not the case during our inspection.

At the North Focused Support Team base there was no CCTV sign in reception to notify people they were being recorded. Following our inspection the service told us a sign had been ordered. We found out of date syringes kit in the clinic room which were removed. The blood pressure machine had a missing cuff, which was replaced following our inspection.

We reviewed the trust risk register and saw a backlog in maintenance was on the register as an extreme risk from September 2023. However, there were no actions which specifically addressed concerns we found in community buildings. Though the scope of works and identification of high-risk buildings was graded as within upper risk appetite, we still found issues in buildings we visited.

However, staff had easy access to alarms in consulting rooms in all the bases we visited.

The service had conducted ligature anchor point audits and assessments for all community bases which mitigated risks to people who used services adequately.

The service mostly ensured there were enough qualified, skilled and experienced people. Staff received effective development through mandatory training and received effective support and supervision.

The single point of access team at Lambeth did not have sufficient staff to meet demand. This included the review of the existing back log of patients, ability to continue to re-assess clinical risk and continue to triage and assess and treat people in a timely way. Though the risk register stated approval had been given in May 2025 to use bank staff and repurpose a vacant post, we did not see evidence these posts had been filled.

Following our inspection we raised these concerns with leaders. They provided an action plan which addressed the concerns raised. This included allocating additional temporary workforce to triage people waiting for services, changing the staffing structure to increase clinical support and agreeing additional funding for staffing.

In Lewisham early intervention in psychosis team staffing levels did not meet service demand meaning practitioners carried higher caseloads than recommended by national guidance. The average caseload was 26 with the highest at 27. This was not in line with the NHS England recommended workforce tool developed by Health Education England in 2023, which recommends care co-ordinators have a caseload of 15.

Staff reported delays in recruiting social workers to the teams due to issues recruiting and the interface with local authority recruitment procedures.

The service provided data that showed in the last 12 months 6032 shifts were filled by bank or agency staff and there were no unfilled shifts.

Staff we spoke to across all services gave examples of the impact of vacancies and sickness absence on caseloads and the impact this had on being able to deliver recovery-focussed services. For example, staff told us they were unable to complete recovery-focussed up to date care plans, and we saw this during our inspection. They also described a risk of missing important information about people who used services and a lack of continuity due to the high number of handovers between staff. However, following our inspection, the service provided a care plan and risk assessment audit for June 2024 to June 2025 which showed 80% of staff felt care plans were recovery-focussed.

We reviewed board papers for May 2025 which stated that trust-wide vacancy data showed the trust was not meeting the vacancy target across all staff groups.

The service provided data that showed in May 2025 there were 426.3 whole time equivalent (WTE) staff in community services against an establishment of 507 WTE, a short fall of 80.7 WTE across all grades and roles, except doctors. In June 2024 there was an establishment of 589.7 and actual staffing of 455.8, a shortfall of 133.9. Though this was an improvement in shortfall, the staffing establishment had decreased and there remained a vacancy rate of 16%.

We requested, but the service did not provide, evidence of any staffing establishment reviews to assess required staffing levels and capacity against service demand.

Staff described financial considerations impacting on recruitment. They told us all vacancies had to be agreed by a vacancy control panel, even if they were already within agreed establishment, which could delay recruitment. Following our inspection, the service provided information that showed they had systems and processes to ensure posts were recruited to. For example, there was a process to requests recruitment decisions outside of the vacancy panel meeting to address any urgent staffing needs.

The trust’s overall sickness absence rate for the last 12 months was 4.3%. The service provided data for community teams which showed an average sickness absence rate of 7.8%.

The service mostly had enough medical staff to provide safe care and treatment. In some teams, staff told us there was long term use of locum consultants. The service did not provide data on the number of shifts filled by bank or agency doctors. However, they provided data that showed in May 2025 there were 3.8 WTE medical vacancies across the service.

However, in the Lewisham Early Intervention in Psychosis (EIP) team the overall caseload of 281 was managed by 1 consultant supported by a speciality doctor and 2 trainees on rotation. Staff told us this was a higher caseload than for other community and EIP teams in the trust. They were able to access cover from other EIP consultants and consultants in the home treatment teams when needed through an informal arrangement.

Staff received regular supervision, which was combined managerial and clinical supervision. The service provided an audit of supervision carried out between April 2024 and June 2025 which showed over 95% of staff across all teams had received supervision every 6 weeks.

The service mostly ensured staff received appropriate training for their roles. Compliance for mandatory training was above the trust target of 85% in all directorates, except Lambeth which was 81%.

Compliance with level 2 training in working with people with learning disabilities and autism 27% in Croydon, 19% in Lambeth, 32% in Lewisham and 21% in Southwark. The service told us this was due to limited availability, and they overbooked places to allow for potential cancellations that may occur on the day or shortly beforehand. They had set up a waiting list each training date, so if any cancellations happened, staff were automatically enrolled. Following our inspection, the service provided information to show compliance was 30% across community services, in line with targets.

The service assessed and managed the risk of infection and detected and controlled the risk of it spreading.

The service had appropriate policies and guidance for staff to follow in relation to preventing and controlling infections. Staff could access guidance on infection prevention and control from the infection prevention and control policy on a page guide, available in all bases.

We looked at clinic rooms, consultation rooms and reception and waiting areas at the locations we visited. All were visibly clean. In some areas, staff used ‘I am clean’ stickers to indicate when items and equipment had been cleaned and were ready for use.

Clinic rooms had suitable facilities for staff to wash their hands and had personal protective equipment available for staff to use. Cleaning records were up to date and demonstrated all areas were cleaned regularly.

However, some external areas and entrances were not visibly clean. At the North Focused Support Team base the entrance to the building had rubbish thrown in the parking area. Staff were unclear whose responsibility it was to keep it clean. Our inspection team highlighted this to managers who took immediate action to address these risks.

At the Lambeth early intervention team base there were patches of damp around the building including mould in consulting rooms. There were 5 meeting rooms for appointments with people who used services. These had been redecorated several times but there was still a leak in the roof. Staff told us this had been escalated but no action taken to address this and people who used services had complained about the damp. We reviewed the environmental risk assessment completed in May 2025, this did not include any reference to damp in consulting rooms or remedial action taken.

The service did not always ensure that medicines and treatments were safe and meet people’s needs, capacities and preferences. They did not always enable people who used services to be involved in planning, including when changes happened.

The service had some systems and processes in place to try to safely support people with their medicines in the community. However, these were not always followed. Areas of good practice were not widely adopted across all teams.

Staff had access to an electronic care records system which linked in with acute trusts and some GP surgeries across London. This allowed them to view admissions and discharges. However, the information was not always up to date and staff often relied on this to inform them about what medicines were prescribed for people.

Some people who used services who were on oral antipsychotic medicines had not had their medicines reviewed in the past 12 months. We saw 1 care record where someone on oral antipsychotic medicine last had their medicines reviewed by a doctor in September 2023. This increased the risk of harm to people who used services as their GP and the service did not always work collaboratively to share information about the prescribing and monitoring responsibility of these medicines.

The service had processes for monitoring the physical health of people who used services. Data showed in Lewisham early intervention team 81% of people had received an annual physical health check and 75% of people in Lewisham Neighbourhood 1 CMHT received an annual physical health check.

Staff told us they spoke to people who used services about side effects they experienced. For those prescribed clozapine (an antipsychotic medicine with strict monitoring requirements), recognised side-effect rating scales were used to monitor changes over time. However, these scales were not consistently applied to people taking other antipsychotics. This meant that there was no record to monitor whether a person’s was improving or deteriorating over a set period.

Staff did not use electronic prescribing systems, they told us that systems existed to do this, but these had not been activated for community services and there was no planned start date. Staff told us this increased the burden on doctors, who had to hand write prescriptions.

Staff told us that they received good support from the pharmacy team who provided a clinical pharmacy service, as well as arranging for supply of medicines and disposal of medicines no longer required. Pharmacists supported clinicians to review people’s medicines and improve patient safety. Pharmacy technicians were embedded into clozapine clinics (clozapine is an antipsychotic medicine with strict monitoring requirements). They worked closely with the community teams to ensure continuity of care and positive outcomes for people who used services.

Clinic rooms were clean, temperature controlled and with appropriate medicines storage facilities. Staff administering medicines in people’s homes had access to adrenaline in the medicine bag. Staff had designated bags and an authorisation card to carry medicines and administer them in people’s homes.

The trust pharmacy team participated in clinical research, which contributed towards improved outcomes for people. They contributed to published articles in 2024 on severe neutropenia unrelated to clozapine in patient receiving clozapine and the long-term impact of 3-monthly paliperidone palmitate on hospitalisation in patients with schizophrenia.