South London and Maudsley NHS Foundation Trust

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

This means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

At our last inspection we rated this key question as good. At this inspection the rating has changed to requires improvement. This meant the effectiveness of people’s care, treatment and support did not always achieve good outcomes or was inconsistent.

Most people admitted to the health-based place of safety stayed for more than 24 hours which is not in line with the Mental Health Act code of practice. Whilst the trust had guidance to ensure people were detained under an appropriate legal framework upon expiry of Sections 135 and 136 of the Mental Health Act this was not being used appropriately with documentation of the decisions made including capacity assessments. This is a breach of regulation 11 Need for consent.

However, assessments and care records were completed and updated correctly by home treatment team (HTT) and crisis outreach service staff. Care plans were individualised, involved family members or carers and staff encouraged people who used services to live healthier lives.

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 home treatment teams made sure people’s care and treatment was effective by assessing and reviewing their needs with them.

We reviewed 17 care records for people using the home treatment service. Staff had completed a comprehensive assessment of each person in a timely manner. The assessment included information about the reason for referral, mental state examination and a thorough history of their mental and physical health. Staff assessed social circumstances, which included drug and alcohol assessments.

Staff assessed and monitored people’s physical health. When people had a physical health diagnosis it was recorded and staff monitored it, liaising with other health care professionals and they discussed it within multidisciplinary meetings.

Staff developed care plans that met the needs identified during assessment. Care plans were individualised and written in the person’s voice. They were holistic and recovery oriented and included people’s goals with steps on how to achieve them. When appropriate, carers and families’ views were noted.

Our on-site review of records confirmed that staff at all locations updated care plans when necessary. Staff said the trust did not have set guidance on when care plans had to be updated but described the importance of keeping them up to date.

The service had a co-produced model of care to deliver crisis services in line with evidence-based good practice.

The service clearly outlined expected standards of crisis care. A crisis care model was designed with staff, carers and people who used services and included statements on how people said they wanted to be treated in a crisis. The model outlined what care people should expect to receive when they were in a mental health crisis.

The service had a joint operational policy for the HBPoS. This had recently been reviewed and updated. However, the policy was still to be ratified and implemented at the time of our inspection. The updated policy included reference to key legislation and good practice guides such as Health London Partnership (2023) Mental Health Crisis Care for Londoners: London’s Section 136 Pathway and Health Based Place of Safety Specification. It included guidance for staff on admission for people under the age of 18 and restrictive practices.

Staff assessed and monitored physical heath and liaised with and referred to specialists when required. People using the home treatment teams, attended the trust’s physical health clinics for testing and monitoring. These provided blood tests for people taking clozapine.

The service told us they were working with the National Confidential Inquiry into Suicide and Safety in Mental Health regarding development of a 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 the South West London integrated care board (ICB) to take forward suicide prevention priorities.

The staff involved in providing care and treatment worked well within and across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

Staff described positive working relationships within the multidisciplinary teams (MDT) for each service. They could share concerns and offer constructive challenge across roles and grades. The MDTs met regularly at handovers, zoning meetings, MDT meetings, case management meetings and governance meetings. We observed 3 handover meetings and saw staff of all roles attended. Staff reviewed people using services, including risks and safeguarding concerns and made plans. We reviewed minutes of MDT meetings for the last 3 months. Meetings were attended by all relevant staff but there was variation in the frequency of them across the directorates.

Members of the home treatment teams worked closely with inpatient wards and adult community mental health teams to ensure effective handovers when people were admitted to or discharged from the service.

Staff described how they worked with external teams to ensure that people who used services received holistic care and support. For example, consultant psychiatrists attended monthly meetings with the lead from a local service supporting people with drug and alcohol issues to discuss complex cases.

Managers from HTTs attended complex patient reviews with external partners to share information about patients who presented at different emergency departments across London.

The trust had a memorandum of understanding with the local police force. Managers attended monthly meetings with the police and a quarterly trust-wide meeting to address any issues in ways of working together.

The service supported people to manage their health and wellbeing to maximise their independence, choice, and control. The service supported people to live healthier lives and where possible, reduced their future needs for care and support.

Staff supported people to live healthier lives through signposting to relevant services in the community. For example, the welcome pack given to people using the HTT in Southwark included information on gardening therapy groups people could attend.

During visits we observed staff giving advice and support on ensuring people ate healthy food and had good sleep hygiene. We saw staff signposting people to community art groups.

HTTs included occupational therapists who supported people to build skills to maximise their independence. We saw an example of support being handed onto a community occupational therapy team to ensure continuity.

Staff supported people to take part in activities that promoted physical health and wellbeing. For example, a member of staff told us about a football group they ran for people who used services.

The service used recognised outcome scales to rate and monitor the outcomes of individuals accessing the home treatment teams. The trust was using Dialog to measure treatment satisfaction, but this had not yet been implemented for the home treatment teams.

Staff used recognised outcome scales to rate and monitor the outcomes of individuals accessing the home treatment teams. This included the Health of the Nation Outcome Scales (HoNOS) and a nationally recognised patient rated satisfaction scale.

The trust participated in relevant national audits. For example, it participated in the Prescribing Observatory for Mental Health Audits (POMH-UK) audit in rapid tranquilisation for 2024 to 2025.

The service used an online tool to collate data from patient records and audit standards of care. The results were monitored in monthly directorate level integrated performance and quality meetings.

The service was working to implement other patient reported measures including a patient rated satisfaction scale but the crisis services and HBPoS were not prioritised for the first year of implementation.

Most people admitted to the health-based place of safety stayed for more than 24 hours which was not in line with the Mental Health Act code of practice. Approximately 40% of patients were from outside of the trust’s geographical boundary which contributed to assessment delays. Whilst the trust had guidance to ensure people were detained under an appropriate legal framework upon expiry of Sections 135 and 136 of the Mental Health Act this was not being used appropriately with documentation of the decisions made including capacity assessments.

People who came to the health-based place of safety were detained under Section 135 and 136 of the Mental Health Act. Most of the people stayed longer than the 24 hours. This was not in line with the Mental Health Act code of practice which states patients cannot continue to be detained beyond the 24-hour legal timeframe. A 12-hour extension can be applied for in emergency situations, but this was not documented in the patient care records.

Data received from the trust for April 2024 to March 2025 showed that 446 out of 481 (92%) patients stayed longer than the 24 hours statutory detention period. Out of those 446 patients, 382 (86%) were detained for over 36 hours and 64 (14%) were detained between 24 and 35 hours. A proportion of these delays were linked to patients from outside the trust’s geographical boundary, which accounted for approximately 40% of admissions and contributed to challenges in arranging timely assessments and transfers.

Whilst on site, we reviewed 9 records of patients who had stayed beyond 24 hours in the HBPoS. Four patients had stayed for over 5 days, 2 had stayed for over 2 days and 2 patients stayed between 24 and 35 hours.The service did not follow their own policy when patients stayed in the health-based place of safety for longer than the 24-hour period. This issue was compounded by the complexity of managing patients from outside the trust’s area, which often required coordination with external services. The policy detailed 5 specific actions should have occurred for each situation, including a mental state review, formal capacity assessment, an incident raised to highlight unlawful detention, a conversation with the patient about their rights, and the legal framework that was being used to keep them at the health-based place of safety.None of these actions had occurred.

The service had not considered a deprivation of liberty safeguards application or a potential high court or court of protection application despite 4 patients being held for over 5 days, which was stated within their operational policy.

The service had not ensured that patients were made aware of their rights upon expiry of the legal detention period. None of the records we reviewed demonstrated a discussion with the patient about their rights or an explanation about the legal framework being used to continue their detention.

We raised our concerns to the trust who provided CQC with a detailed plan of actions they would take to rectify these issues. This included training to reinforce the need to use a ‘decision tree’ matrix to support the use of the appropriate legal framework and progress to less restrictive care as soon as possible and to ensure the completion of the correct documentation. The trust also took immediate action to introduce out-of-hours senior management support to support staff and escalate delays for people who were in the health based place of safety appropriately.

Staff had received training in the Mental Health Act. The percentage of staff who had completed training in July 2025, against a trust target of 85% was:

• Croydon Directorate 87%
• Lambeth directorate 91%
• Lewisham directorate 92%
• Southwark directorate 93%

Staff received training in the Mental Capacity Act. The percentage of staff who had completed training in July 2025, against a trust target of 85% was:

• Croydon directorate – level 1 86% and level 2 83%
• Lambeth directorate – level 1 91% and level 2 86%
• Lewisham directorate – level 1 91% and level 2 88%
• Southwark directorate – level 1 96% and level 2 92%

The HBPoS displayed information about independent mental health advocacy and patient Section 132 rights.