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

At our last inspection we rated this key question good. At this inspection the rating has changed to requires improvement. This meant people were potentially unsafe and were at risk of avoidable harm.

The service did not ensure that incidents were reported consistently which meant there was a risk of failing to identify themes and areas for learning.

Medicines were not always administered safely or appropriately in the health-based place of safety. Care records showed that people were given medication without being detained under a legal framework. An audit completed by the trust showed that less than 10% of patients administered rapid tranquillisation had the necessary physical health checks afterwards to monitor them and keep people safe. The trust was working to address this shortfall. Medicines charts for medicine administered by the home treatment teams in people’s own homes were not always completed accurately.

Staff did not always use correct techniques during restraint of patients in the health-based place of safety (HBPoS) and the trust recognised this needed to improve and were arranging additional training.

Staff in the home treatment teams did not all have access to working alarms to obtain support in an emergency.

However, the home treatment teams (HTT) and crisis outreach staff were aware of how to raise incidents and gave examples of changes made as a result. Staff were aware of safeguarding procedures and were using them appropriately. Clinical areas and appointment rooms were clean. The home treatment teams assessed and managed risks for individual people and kept these under review.

This service scored 47 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff in the health-based place of safety did not use the patient safety incident response framework consistently. This meant there was a risk that patient safety incidents might not be identified, or lessons learnt to promote good practice.

Health-based place of safety (HBPoS) staff said they knew how to report patient safety incidents and clearly described the process, however data provided by the service showed that incidents were not raised consistently. This included not always reporting extended stays in the HBPoS and unlawful detentions. Staff in HTT and the crisis outreach service (COS) said they raised incidents appropriately and described the types of events where an incident would be raised.

The service reported 2 serious incidents within the last 12 months. Both incidents related to deaths of people who used HTT services. One of these incidents was still under investigation at the time of the inspection. The closed investigation did not identify any areas for improvement for the trust.

Incidents were reviewed by managers in a daily incident huddle. Following our on-site inspection, we requested copies of the documents used to record this meeting. These did not clearly record what actions would be taken in response to an incident and who was responsible for completing this.

Staff had opportunities to learn from incidents. The trust sent staff emails to promote the learning from incidents. We observed handovers where incidents and examples of learning were discussed.

Staff understood the duty of candour and we saw posters displayed in offices giving information on this. Staff and managers recognised the importance of engaging and involving patients, families and staff following a safety incident including where appropriate in the investigation. The trust monitored the use of duty of candour trust wide, and this data was available for the trust geographical directorates. However, where patients were experiencing delays in the HBPoS it was not clear if they had received a clear explanation from staff of the reasons for the delay and the steps being taken. Following the inspection the trust recognised this as an area for improvement and implemented a clinical review and a record that this communication was taking place.

Staff said they were supported after any serious incidents. They were debriefed and could access counselling and occupational health services. During the inspection we looked at an incident of restraint in the HBPoS. It was not clear if the patient had been supported as part of the debriefing process to participate if possible.

The trust had systems in place for patients to access crisis services. These had been developed with healthcare partners and other emergency services. They promoted continuity of care, including when people moved between different trust services.

Referrals were made to HTT through an agreed pathway and discussed during handover meetings. We observed handover meetings at all HTT locations, where the individual needs and risks of people using services were discussed and documented.

The service employed link workers in HTT who acted as discharge coordinators to ensure effective transfer of care between the service and community mental health teams.

Staff at the HBPoS facilitated a safe handover when the patient arrived. They completed a patient admission checklist with police which included their reason for detention, items found during search and any current medication.

We observed a case management meeting at the acute referral centre ARC. We saw staff reviewed all people waiting for an inpatient bed. Staff were proactively assigned actions to ensure people moved to the most appropriate service as quickly as possible.

We requested information about how Right Care Right Person (RCRP) had been implemented and monitored across the trust’s different HTT, crisis outreach and HBPoS locations. RCRP is an initiative to ensure that people receive the correct treatment from emergency services during a mental health crisis. We were provided with RCRP joint briefing and escalation process documents in conjunction with NHS England, police and the other 10 mental health trusts across London. Managers said quarterly meetings were held to discuss incidents where problems had occurred in the working between emergency services.

Not all staff had completed the relevant safeguarding training. Staff demonstrated a good understanding of safeguarding. Staff assessed safeguarding concerns and where appropriate made safeguarding referrals in line with the trust procedures.

Staff were trained in safeguarding but data provided following our inspection showed mixed staff compliance when compared to the trust’s target of 85%. Safeguarding training compliance for safeguarding adults and children level 1 and 2 was above the trust target in all directorates. Compliance with level 3 safeguarding children training was also above 85% except in Lambeth directorate, which was at 74%.

However, compliance for safeguarding adults’ level 3 was below the trust target in Lambeth and Southwark directorates at 66% and 75% respectively. Managers in Lambeth told us this was due to 12 staff not being compliant, with 11 of those based within the HTT. The trust told us 5 members of staff were booked to attend training but didn’t provide a timescale.

Staff were guided by up-to-date 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.

Staff discussed any safeguarding concerns in handovers. They showed an awareness of potential safeguarding concerns and told us they were well supported by trust safeguarding leads. We found evidence of appropriate safeguarding actions taken for someone who used HTT services. They had a physical disability, and they needed an interpreter. We reviewed their care records which reflected a safeguarding referral to support them, their family members and an interpreter was requested for all appointments.

Staff assessed and recorded any potential safeguarding issues. We reviewed 17 care records and staff had recorded if children were living with the person and whether this warranted a safeguarding referral or not.

The trust conducted 3 internal clinical audits in 2024 to 2025 on staff awareness of the Mental Capacity Act, documentation of the Mental Capacity Act and safeguarding children.

The home treatment teams had processes in place to assess and manage risks based on the needs of individual people using the service. The handover and recording of risks for people in the health-based places of safety needed to be strengthened. Use of restrictive practices in the health-based places of safety had increased between December 2024 and March 2025. We found an example of staff not using the correct restraint, and the trust acknowledged that improvements were needed and were arranging additional training for staff. Some staff working in the home treatment teams did not have access to an operating alarm to gain assistance in the event of an emergency.

The trust had an ongoing programme to implement the new approach to promote a more holistic, person centred approach to improving the safety of people using services. Whilst the programme was ongoing, they provided an information document for staff which outlined best practice principles in relation to understanding each person’s situation. Risk formulation tools had been developed and added to the electronic care record system for staff to use.

Risk was being appropriately identified and managed by the home treatment teams. We reviewed 17 care records for people using the home treatment service. Staff had completed risk assessments, and they were up to date. Risk management plans were developed following assessment and included all identified risks. They were individualised and written in the person’s voice. They included early warning signs, how to manage symptoms when becoming unwell or in a crisis, and contact numbers. However, 2 people did not have a completed risk management plan.

We observed handover and zoning meetings across all home treatment team locations. Known and emerging risks were discussed. The service used a ‘zoning’ system to indicate the frequency that risks for individuals were reviewed and discussed. 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.

Staff in HTT and crisis outreach teams said they knew the people on their caseload well and when there was a change in circumstances which needed their input. They facilitated joint visits with other clinicians when required.

Multi-disciplinary meetings (MDT) were well attended and showed evidence of considering individual people’s needs.

A prevention of future death report from the coroner’s office was issued to the service in the 12 months before our inspection. This highlighted concerns about risk assessments of people who used services. The trust’s action plan response included an improved risk evaluation process and trust-wide increased auditing of risk assessments. It was positive to see the progress in the home treatment teams.

The assessment and management of risk was less robust in the health-based places of safety. People were often staying for long periods of time, which meant that handovers needed to take place between shifts. These were happening but were not well documented. Immediately following the inspection, the trust implemented the use of the nursing handover template in line with practice in other parts of the trust and the use of a daily MDT safety huddle.

Staff completed training on reducing restrictive practice. This enabled them to develop knowledge and skills in the least restrictive management of people when they had a heightened emotional reaction. This was bespoke training to the trust and had been developed following a fatal incident of restraint in 2010, with support from family members, community groups and people who used services. Compliance with this training was 90% for staff working in HBPoS against the trust target of 85%.

Following our on-site inspection, we requested and received information about a serious incident in the HBPoS. This incident highlighted the use of inappropriate restraint techniques by several members of staff. Following our inspection, we raised these concerns with senior leaders. They provided an action plan which addressed the concerns raised. They took immediate action to ensure all staff had completed the appropriate training and to review all incidents of restraint in the daily incident huddles.

We reviewed the reducing restrictive practice report for December 2024 to March 2025. The service reported 96 incidents of restrictive practice in the HBPoS. This included: incidents of physical restraint; 3 incidents of chemical restraint; 28 incidents of seclusion; 2 incidents of prone restraint; 2 incidents of mechanical restraint; 22 incidents of rapid tranquilisation. This was an increase from the previous 4 months, when the service reported 54 incidents of restrictive practice in the HBPoS between August and December 2024. A trust-wide quality priority to reduce the number of restraints was in place from 2021 and bespoke training was provided to staff.

The trust provided results of a survey which showed that staff from the home treatment teams knew what action to take if patients did not attend their appointment. The procedure for staff to use if patients do not attend was being reviewed at the time of the inspection to align with the transformation of community services.

The service did not always operate consistent processes to protect staff who were lone workers. Not all staff had individual alarms and mobile phones. Bank staff told us they were not given a mobile phone and had to use their personal phones. Staff in Croydon HTT did not have personal alarms and staff in other teams told us the alarms did not always work. Managers told us this was being looked at by the trust health and safety team. However, in other teams such as Lewisham HTT, staff had access to alarms which included a panic button and a record of time entering and leaving premises.

The service identified and managed potential environmental risks in the care environment. However, not all facilities supported the delivery of therapeutic care. At the HBPoS at the Maudsley Hospital, patients did not have direct access to outside space and fresh air which was not in line with the Mental Health Act Code of Practice.

Most premises we visited were fit for purpose with soundproofed clinic rooms and panic buttons. However, some staff told us they experienced problems with their working environment. For example, they told us about water and taps not working in the building all the time. At the Croydon HTT premises rooms were not soundproofed adequately. Staff told us action was being taken to address this.

The service conducted ligature anchor point audits for all crisis and HTT bases which mitigated risks to people who used services adequately. An annual ligature audit was carried out on the HBPoS in November 2025. The audit was comprehensive and identified additional control measures needed to manage risk. It had associated action plans for managers and estates colleagues to ensure risk was managed.

Staff in the HBPoS had access to appropriate equipment, including ligature cutters and emergency equipment.

At the HBPoS at Maudsley Hospital, patients had no direct access to outside space and fresh air which was not in line with the Mental Health Act Code of Practice. Managers told us a bid for funding had been submitted to the trust charity to address this. Staff believed they would not be able to escort patients outside for fresh air because that this would automatically end the Section 136 detention. Patients in the HBPoS at the Maudsley Hospital did not have access to an ensuite toilet. Three rooms shared a bathroom.

We reviewed the workplace environmental risk assessment for the HBPoS. All identified risks were graded low, with measures in place to reduce the impact of any identified risks.

Whilst the home treatment teams had staff vacancies, staffing levels were monitored daily to ensure there were enough staff. Staff turnover was low and recruitment was ongoing. Completion of mandatory training mostly met the trust target of 85%. Staff particularly in the Southwark home treatment team fell below the trust target for the completion of basic life support training and some staff still needed to be booked for this training.

The service provided data that showed in May 2025 there were 34.2 whole time equivalent (WTE) staff for HBPoS with no vacancies. There were 104 WTE staff for HTTs, against an establishment of 119, a shortfall of 15 WTE staff.

Staff turnover in the 12 months before our inspection was low across all locations. The HBPoS had no staff turnover. Staff turnover at the HTTs was 6% at Lambeth, 4% at Croydon, 3% at Lewisham and 1% at Southwark.

Managers reviewed staffing levels daily to ensure there were sufficient staff on duty and to maintain safer staffing levels. The service did not use any bank or agency staff. Some staff gave examples of posts not being filled immediately when staff left due to financial pressures and the need to get the necessary approval to fill vacancies.

Leaders told us they had held recruitment days to encourage staff to apply for nurse training and nurse roles and these had been successful in recruiting nursing staff.

The service ensured staff received appropriate training for their roles. Overall compliance for mandatory training, against a trust target of 85% was:

• 92% in Croydon directorate
• 85% in Lambeth directorate
• 88% in Lewisham directorate
• 86% in Southwark directorate

However, compliance with basic life support training was below trust target in all directorates, except Croydon. It was 73% in Lambeth, 81% in Lewisham and 66% in Southwark. In Southwark directorate, 11 staff in the HTT and 4 staff in the HBPoS were non-compliant with basic life support training, of these 2 had training booked.

The service assessed and managed the risk of infection. They 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 and the policy was made more accessible in a single page format.

Not all staff in Lambeth directorate had completed infection control training. Eighty four percent of staff had completed level 1 training and 77% level 2. This was below the trust target of 85%.

Staff in the HBPoS had access to appropriate personal protective equipment (PPE) and handwashing facilities.

Most premises we visited were visibly clean, with clean furnishings and access to water machines. Staff maintained equipment and in the HBPoS equipment was labelled to indicate it had been cleaned and was ready for use.

Medicines were not always administered safely or appropriately in the health-based place of safety. Care records showed that people were sometimes given medication without a clear record of the rationale for the use of an appropriate legal framework. Staff understood the importance and how to monitor patients after the administration of rapid tranquilisation. Medicines charts for medicine administered by the home treatment teams in people’s own homes were not always completed accurately to confirm the medication had been administered.

Staff did not always follow good practice in medicines management and were not always in line with national guidance.

We reviewed 14 care records at the HBPoS. We found that 12 people were given medication without being detained under a legal framework. Staff had recorded that people lacked capacity, but a formal mental capacity assessment had not been completed. Four people were given medication under restraint after the 24-hour detention timeframe had expired.

Systems and processes were in place to support people to receive their medicines safely in the community. Prepack medicines were available in the HTTs, which were stored securely. When medicines were supplied to people, staff were required to record this on the medicines chart, however this was not always documented. Additionally, staff had not consistently documented when they had observed people taking their medication, meaning that compliance was not always accurately recorded.

Most HTTs had access to emergency medicines. Staff told us this was taken out on visits when they administered long-acting depots to people in their home. However, the Croydon HTT did not have adrenaline for anaphylaxis available on the premises. This was rectified during our on-site inspection.

Pharmacy staff were embedded in HTTs and provided clinical support. Staff had access to information about medicines people were prescribed by different services through the trust’s care record system.

The HTTs had a process to initiate and titrate clozapine for people in the community. Clozapine is an antipsychotic which requires regular blood monitoring. Staff completed vital observations whilst people were initiating treatment in their homes and knew how to escalate any identified issues.

Staff reviewed the effects of medication on patients’ physical health regularly and in line with national guidance. Trust data showed that on average 90% of people within the crisis and HTTs had some of their physical health checks completed.

People’s medicines were regularly reviewed by the multi-disciplinary team. Staff discussed any side effects with people although rating scales were not routinely used in the trust but were available for staff if required. Concerns were escalated in daily meetings, and were discussed, reviewed and actions put in place to ensure people remained safe. All medicines were recorded within the care record on assessment.