South London and Maudsley NHS Foundation Trust

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

This means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last inspection we rated this key question good. At this inspection the rating has changed to requires improvement. We found 2 breaches of the regulations in relation to effective governance systems and care records.

Requires improvement: This meant governance systems and the culture in the service did not always support the delivery of high-quality, person-centred care.

However, the service had inclusive leaders at all levels who valued diversity in the workforce. The service worked collaboratively with stakeholders, partners and communities to develop and deliver services.

This service scored 61 (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 had a shared vision, strategy and culture that was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding and meeting the needs of people and their communities.

Most staff described supportive cultures within their immediate teams that were focussed on delivering high quality care for people who used services. However, some staff described concerns about the culture in some teams and a lack of support.

Some staff told us they were not always able to contribute to decisions that impacted how they delivered services. They told us of decisions to change equipment based on financial considerations which meant they did not have the equipment to carry out their role safely.

Staff did not always feel they were involved in or able to contribute to discussions about strategy for their services. They did not feel involved in planning services.

However, following our inspection, the service provided evidence of staff involvement in the community care development programme. This included a local delivery group made up of staff, carers and people who used services. Senior leaders met with staff as part of the programme.

Staff were able to describe the trust values and explain how they applied them in their everyday work. They could explain the trust values and behaviours framework which had 3 main components of kindness, respect and togetherness. The framework outlined the kind of behaviours that should and should not be shown under each of those components.

The trust had a clear strategy for 2021 to 2026 which focused on 5 key ambitions and was shared on the trust website.

The service had inclusive leaders at all levels who understood the context in which staff delivered care, treatment and support. They had the skills, knowledge, experience and credibility to lead effectively and did so with integrity, openness and honesty.

Some staff told us local and senior leaders were visible and often visited team bases. They said they were readily available to support staff, and they could escalate concerns to leaders through weekly meetings. Staff described supportive working relationships with local leaders and managers. However, some staff felt that when escalating issues to leaders this did not always lead to change.

We spoke with senior leaders in each directorate. They showed a good understanding of the services they managed, and their challenges. Leaders spoke with openness about improvements needed in the services they led.

Leaders told us they were proud of how teams were working to provide high quality care. For example, leaders talked positively about the work staff and managers in Lewisham had done to change the culture within services by including principles of the patient and carer race equality framework in their work.

Leaders and managers in the service described strong, supportive working relationships with trust leaders. There were clear structures for leaders to meet with and report to trust leadership.

Lewisham directorate had strengthened clinical leadership and had 4 matrons with responsibility for ensuring the quality of services.

Staff received training and support to develop into leadership roles, for example through the team leader programme.

The service did not consistently create a positive culture where people felt that they could speak up and that their voice would be heard.

Most staff told us they felt supported to raise concerns by local managers and leaders and that they were mostly listened to. However, some staff gave examples of not being listened to and some told us they felt that action was not taken to address concerns they raised. Some staff told us they did not always feel safe to speak up.

Staff told us that though they did not always get feedback when they escalated issues, they hoped this would improve following the introduction of the staff representatives. Staff representatives now attended board meetings.

However, staff were aware of the role of Freedom to Speak Up Guardian and knew who to contact to raise concerns. A Freedom to Speak Up Guardian works alongside the trust’s senior leadership team to ensure staff have the capability to speak up effectively and are supported appropriately if they have concerns regarding patient care. Managers completed mandatory level 2 training in ‘Listening Up’. The trust had a Freedom to Speak Up strategy which was developed following a series of engagement events and presentations in 2024. In October 2024, Freedom to Speak Up ambassadors and champions promoted the role of Freedom to Speak Up in their areas and the guardian spoke on a live broadcast to staff. Audits for June 2024 to June 2025 showed 97% of staff knew how to access their local Freedom to Speak Up ambassador.

The Freedom to Speak Up Guardian reported themes from cases to the board through the quality committee. The top 5 themes from cases which were about staff safety or wellbeing were bullying and intimidation by senior staff, targeted harassment, failure to address grievances, discrimination and exclusion and undermining of professional integrity. There were 3 broader themes raised by staff about the trust’s approach to financial turnaround, the trust’s response to extremist riots in summer 2024 and closure of the staff nursery. There were 27 cases raised trust-wide to the guardian where there was a patient safety element to the case.

The service valued diversity in the workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The trust undertook equality monitoring of its staff and reviewed its Workforce Race Equality Standard (WRES) and Workforce Disability Equality Standard (WDES) results. WRES and WDES data are only available at trust-wide level.We reviewed the May 2025 WRES report to the equality and diversity committee, which was based on published WRES results for 2023 to 2024. This showed the trust had improved in 7 of 9 indicators from the previous WRES report scores. The trust had seen a 2% increase in the representation of people from ethnic minority groups in the workforce. The relative likelihood of white applicants being appointed from shortlisting compared with staff from ethnic minority groups had improved by 0.1%. The relative likelihood of white staff accessing non mandatory training and professional development compared to staff from ethnic minority groups had decreased from 0.68 to 0.97. The number of staff from ethnic minority groups entering disciplinary processes had decreased by 0.7%. The number of staff from ethnic minority groups experiencing bullying and harassment from staff in the last 12 months had decreased by 1.7%. The percentage difference between the proportion of staff from ethnic minority groups on the trust's board of voting members and the proportion of staff from ethnic minority groups in the overall workforce had improved by 14%.

We reviewed the May 2025 WDES report to the equality and diversity committee, which was based on published WDES results for 2023 to 2024. This showed the number of staff declaring a disability had risen and was higher than the NHS average. The report showed the number of disabled staff compared to non-disabled staff saying that the last time they experienced harassment, bullying or abuse at work, they or a colleague reported it had increased in 2024, though this was still below the national average. The report identified a need for a continued focus on the trust’s civility and respect programme.

Managers had access to a range of policies and tools to help them support staff with disabilities. This included an ‘ability passport’ and access to support for reasonable adjustments. An ability passport is a document that details the reasonable adjustments a staff member with health or disability issues needs at work.

Staff in the service could access support from 5 staff networks which included LGBTQ+, ethnic minority groups, disability, women’s and lived experienced networks. The service had diversity in recruitment champions who took part in all aspects of recruitment for senior staff.

Staff and managers could use the flexible working policy to submit flexible working requests which gave them greater choice in when, where and how they worked. This meant staff could access flexible arrangements to account for personal circumstances such as caring responsibilities and health issues.

The service did not consistently operate effective governance systems that included clear responsibilities, roles and systems of accountability to manage and deliver good quality, sustainable care, treatment and support.

The service had not taken effective action to address issues raised in previous inspections and this impacted on the provision of safe care and treatment.

At our inspection in 2021 we told community based mental health services for adults of working age in Croydon they should ensure they complete and update care plans and risk assessments. During our inspection we saw this was on the local risk register and had been downgraded to a ‘3’. The last narrative stated in July 2024 50% of people who used services had a care plan and 71% a risk assessment. However, on this inspection we found significant gaps in care plans and risk assessments in records we reviewed.

We also told the service it must ensure people who used services who required a Mental Health Act assessment were assessed without undue delay to ensure their safety and that of others. At this inspection we found significant delays to people who used services receiving Mental Health Act assessments.

We told the service it must ensure that all community mental health teams met their target for assessing non-urgent referrals within 28 days. The integrated quality and performance report for March 2025 showed 86% of referrals were first seen within 28 days or less against a trust target of 95%. This was not in line with trust policy or national standards.

Some staff did not meet the Nursing and Midwifery Council code of practice and NHS Professionals record keeping guidelines which required them to maintain accurate and contemporaneous records. This meant staff did not always have current oversight of risks to the health and safety of people who used services.

Local audit processes were not always effective at identifying and addressing quality and safety issues. Staff described and we saw a disproportionate focus on meeting numerical targets for key performance indicators at the expense of content quality in care plans and risk assessments. Teams used an online audit system to monitor compliance with care planning, risk assessments, safety plans and patient feedback. However, we found mixed compliance with completion of the audits. In Lewisham Early Intervention in Psychosis team, the audit was assigned to team members to complete, and this was tracked by the team lead. However, in other teams we were told staff did not always complete audits. For example, in the Lambeth single point of access team staff told us the current audit system was not applicable to their work, so no audits were conducted. In Lewisham community teams we were told there was low compliance with completion of local audits for care plans, risk assessments and crisis plans. Matrons’ audits showed low compliance in these areas, and we found this in records we reviewed onsite. There was little evidence of robust action taken to address these concerns.

There was a system of local governance meetings to ensure information was shared between local teams and up to board level and back to staff in teams. However, in some areas we were told this was newly established and not yet embedded in teams. There was no consistent framework across directorates that confirmed what must be discussed at team or directorate level in meetings to ensure that essential information, such as learning from incidents and complaints, was shared and discussed.

We were told not all relevant staff were able to attend governance meetings. The service had standardised template for local governance meetings, however we found inconsistent recording of these meetings. For example, in Lambeth early intervention service we reviewed minutes for September to January 2024. There were no minutes recorded for 3 of these meetings and the other meeting minutes were not complete. The service told us they were aware of the variability and gaps in meeting minutes. They stated they would implement a standard term of reference for team business and governance meetings and address gaps with team leaders. We reviewed minutes of multidisciplinary team meetings for the last 3 months. There was no standardised agenda and topics discussed, recording of meetings and frequency of meetings varied across teams and directorates.

Managers and staff could access the locating useful clinical information (LUCI) dashboard which had real time data pulled from the electronic care record to monitor service and individual data and outcomes. However, not all staff had completed training and we found inconsistent use of it across teams and directorates.

However, staff had access to the equipment and information technology needed to do their work.

Team managers showed us systems which gave access to information to support them with their management role. This included information on the performance of the service, staffing and the locating useful clinical information dashboard.

Managers and leaders reviewed themes and trends from incidents every 3 months at quality committee. This was then reported to the board in the integrated performance report.

We reviewed the risk registers for each directorate. These reflected risks seen on inspection and gave detail on actions leaders were taking to address risks.

The service had a business continuity management system which clearly identified steps for staff to take in event of disruption such as systems failures and power outages. It included plans to ensure critical and key services continued to be provided.

The service understood its duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The service held regular meetings with external partners to ensure safe systems of care were established. For example, leaders in Lambeth attended regular meetings with the primary care networks to ensure information was shared and services worked together well across primary and secondary care.

The service worked with local stakeholders to implement a new community framework. They held an initial stakeholder event with representatives of carers, people who used services, the voluntary sector and other key partners. The leadership of the local delivery group responsible for implementing the framework included staff, carers, people who used services and voluntary sector partners.

In Croydon, teams were based within an assessment, liaison and wellbeing hub. The hub included voluntary sector partners. We were told up to 850 people each month used the hub as a drop in and this meant people who used services could access community-based services as well as clinical support.

In Southwark directorate managers worked with a local voluntary sector agency to run a befriending service in Peckham. A volunteer co-ordinator employed by the trust supported volunteers to run the service and the service supplied paid sessional workers to the group.

The trust worked in collaboration with neighbouring hospitals and NHS trusts through data sharing agreements. The trust was part of the South-East London Data Sharing Framework which outlined the purpose and processes for personal data processing and sharing in health and care. It included key data sharing principles and was developed by health and social care stakeholders across Southwark, Lambeth, Lewisham, Greenwich, Bexley and Bromley.

The service worked with external agencies to ensure learning from incidents was shared. They sent board briefings to the relevant integrated care board (ICB) and CQC following all incidents. Where appropriate, NHS England and the ICB was invited to closure meetings following patient safety incident investigations.

The service focused on continuous learning, innovation and improvement across the organisation and the local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

Staff were given the time and support to consider opportunities for improvements and innovation. In Lewisham Neighbourhood 1 Community Mental Health Team (CMHT) staff attended learning events as part of a psychological safety collaborative. This aimed to build a culture of learning, openness and staff feeling enabled to report incidents. The collaborative had a senior sponsor to ensure staff were supported to attend sessions.

Staff used quality improvement methods and knew how to apply them. Staff gave examples of quality improvement projects they were involved in. For example, staff told us about working on a quality improvement project to implement daily huddles in their team.

In Lewisham Early Intervention in Psychosis team there was an ongoing quality improvement project to improve access to clozapine and improve up take. Staff had attended training to be able to carry out point of care testing, the service had kit donated and the service was due to start offering this in June 2025.

Staff had opportunities to carry out research activity and were given protected time to do so. Updates on and outcomes of research were shared with staff in team meetings focused on training and education.