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

At our last inspection we rated this key question as good. At this inspection the rating has changed to requires improvement.

The service did not make sure that people could access the care, support and treatment they needed in a timely manner. For the home treatment teams urgent referrals were only seen in four hours for 43% of referrals. Croydon and Lambeth were not meeting the 24-hour referral time for non-urgent referrals. The trust was delivering a digital dashboard for the health-based place of safety to improve the oversight of delays and breaches, but this was not yet in place.

The services understood the needs of their local population and how to meet people’s individual needs. They had a range of methods for people to give feedback and made improvements as needed.

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 made sure people were at the centre of their care and treatment choices and they decided, in partnership with people, how to respond to any relevant changes in people’s needs.

Patient choice and individual needs were reflected in the care records that we reviewed. Care plans and risk assessments were written with clear evidence of the patient voice.

Patients and people said appointments were tailored to their needs and continuity of staff was facilitated where possible to improve patient recovery.

During an observation of a home visit, we observed staff playing meditation music as requested by the person being visited, this was also documented in their care plan.

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.

The service held monthly emergency department and HBPoS interface meetings with local NHS acute trusts and other mental health trusts, as part of the South London Mental Health and Community Partnership.

We reviewed notes from a meeting held on 10 April 2025 which highlighted a discrepancy between the live on-line system for HBPoS availability compared to the actual availability. The meeting notes advised that work was underway to improve communication and prevent police from arriving at a HBPoS that was already at full capacity.

Staff in home treatment teams (HTT) and the crisis outreach service (COS) worked with colleagues in primary care to ensure that the appropriate information was provided upon discharge, including joint appointments to aid the transition process.

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

The trust had arrangements for key information to be made available in different languages and formats to meet peoples needs.

Staff had a language line they could use to access face to face or telephone interpreters for people who used services.

The service made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. The trust made improvements in response to feedback.

The most recent friends and family survey between January and June 2025 was available at a directorate rather than an individual team level. Overall results showed that 88% of carers and 84% of patients reported a good or very good experience during their most recent contact.

The trust held monthly meetings with patients and people who used services to gain their perspective on the level of care received. The trust had a service user, carer and community engagement plan for their care transformation programme. The care transformation programme engagement plan 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 trust 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.

The different directorates had different arrangements for engaging with people who use services and their carers. Some used surveys or met face to face. For example, Croydon and Lewisham facilitated family and carers mental health forums monthly.

Carers could access regular carer forums for people from all ethnic backgrounds. The service engaged with minority ethnic backgrounds through a group that was facilitated by the National Ethnic Mental Health Carer Forum. This was for carers from ethnic minority groups to share experiences, influence change, and shape the future of mental health care.

The service kept a formal record of all complaints. In the last 12 months there were 36 complaints about the service. Twenty-six complaints related to care and treatment. Actions taken in response to the complaints included increased staff training and improved communication between teams. Between July 2024 and June 2025, 2 complaints were upheld by the Parliamentary and Health Service Ombudsman (PHSO) and 1 complaint was referred to the PHSO.

Two people we spoke with who had used the home treatment service had made a complaint. They said staff had dealt with it quickly and it had been resolved to their satisfaction.

The service did not make sure that people could access the care, support and treatment they needed in a timely manner. For the home treatment teams urgent referrals were only seen in four hours for 43% of referrals. Croydon and Lambeth were not meeting the 24 hour referral time for non-urgent referrals. The trust was delivering a digital dashboard for the health-based place of safety to improve the oversight of delays and breaches but this was not yet in place.

The service provided data that showed the average time in May 2025 from referral to a home treatment team to first clinical contact was:

• Lewisham HTT – 25.9 hours
• Croydon HTT – 31.5 hours
• Lambeth HTT – 36.5 hours
• Southwark HTT – 20.8 hours

This was not in line with NHS England standards which state people requiring urgent care should be seen by community mental health crisis teams within 24 hours of referral.

Data showed that Lewisham HTT had met the 24-hour standard in only 3 months between June 2024 and May 2025. Croydon HTT had not met the 24-hour standard, with the longest average time being in January 2025 at 121 hours. Lambeth HTT had not met the 24-hour standard in any month. Southwark HTT had met the standard in 6 out of 12 months.

The service did not meet NHS England standards which state people requiring most urgent help are seen within 4 hours. Data showed in May 2025, 43% of people with an urgent referral priority were seen within 4 hours. The service had not met the standard in any month between June 2024 and May 2025, with lowest compliance with the standard in October 2024 at 13% and highest in April 2025 at 50%.

The service told us they were reviewing how HTTs were working to ensure they had the best offer possible within resource and to manage demand effectively. They did not submit any action plans associated with this work.

The service had a 24-hour urgent mental health helpline (111 option 2 service) for professionals and people who used services, which referred people who used services to the most appropriate team. The service provided data between December 2024 and May 2025 that showed an average of 73% of calls were answered against a target of 78% and 20% of calls were abandoned against a target of 3%.

We identified someone under the crisis outreach service (COS) who had their Mental Health Act Assessment (MHAA) been delayed for 6 weeks. Staff had obtained a Section 135 warrant, but the assessment was delayed due to a large number of referrals, limited police availability and eventually the lack of an available hospital bed once the assessment had been organised. Staff had maintained contact with a close family member during this time to check on the person’s welfare.

Data provided to us by the trust after the inspection confirmed the average patient length of stay in the HBPoS during the last 12 months was 63 hours, compared to the 24-hour legal period for detention under Section 135 and 136 of the Mental Health Act, with a possible extension up to 36 hours. They told us there was a significant peak between September and November 2024 which impacted the overall 12-month average and recently the average reduced to just over 50 hours.

Senior leaders said the service started a specific workstream in September 2024 focused on improving outcomes and experience for people admitted to the HBPoS. It had completed a root cause analysis and work was in progress. This included developing a decision tree and training for staff on appropriate application of the Mental Capacity Act, to develop a HBPoS length of stay report to monitor data and to develop a local tracker to monitor the cause of breaches. These measures were not in place at the time of our inspection.

Staff and leaders actively listened to information about people who are 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 99% of staff had completed training. In Lambeth, Lewisham and Southwark 95% of staff had completed training.

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. This included the use of the Mental Health Act and restrictive interventions such as restraint.

The trust was a pilot site for 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 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.

People using the home treatment teams were supported to plan for their future and staff supported people’s discharge to the appropriate services.

We reviewed 17 care records and they all included discharge plans which showed where the person was to be referred to and staff liaison with other teams or services.

Staff ensured all relevant healthcare professionals were involved in planning the care and treatment of people with complex needs. Staff made referrals to other services such as physical health, substance misuse or other teams within the trust. They liaised with services that could aid people’s social circumstances such as employment or housing.