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

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

The service did not have robust governance systems in place to ensure effective oversight of service delivery or risks. Inconsistent collection of data about outcomes and performance made it difficult for improvements to be identified. Not all staff felt involved in making decisions about services and feedback was mixed about how supported staff felt. Most staff felt able to share concerns, but some did not feel these would be addressed.

Innovation was promoted by the trust with quality improvement embedded in services. The trust had initiatives to support staff equality, diversity and inclusion. The service had effective partnerships with community organisations and other stakeholders.

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.

Most staff whilst not showing an awareness of the trusts vision and strategy understood the challenges and the needs of people and their communities. Some staff said they did not feel involved in discussions about the changes in their services and this made them feel devalued.

Most staff were unaware of the trust’s vision and strategy. They understood the values of the trust.

Not all staff felt involved in planning and making decisions about services. Some staff told us this was done at senior leader level. Some staff told us they did not feel supported in some of the service changes and that managers had cancelled meetings to discuss these changes and how they would impact staff. They told us this had left them feeling devalued and that they had not been treated with respect.

Following our inspection, the trust provided evidence of measures in place to strengthen staff engagement. These included opportunities for staff to contribute through service director monthly forums, location visits, and governance meetings.

Most staff at all levels demonstrated a good understanding of the needs of their populations. Staff in different teams told us about the specific challenges faced by local people who used services. It was evident from how they spoke about people who used services that staff understood how their work contributed to tackling inequalities faced by people.

The service had local managers and directorate leaders who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Some staff said that the trust senior leadership team was not visible.

We spoke with managers and senior leaders in each directorate. They spoke candidly and with great pride about the service. They were experienced and highly motivated and held a good understanding of the needs of people who used services in their directorates, as well as the challenges faced by their staff.

There were opportunities for staff to progress their careers within the trust. We met some staff who had been supported by the trust to develop into more senior roles. Some staff told us they felt managers supported them in their personal and professional development.

Most staff told us they felt well supported in their teams. In some teams, staff spoke very highly of service directors and senior leaders of the trust. In other teams, some staff told us that while local leadership was supportive and highly visible, service and trust-level leaders were not visible.

Some staff told us development opportunities were very limited due to financial restrictions.

The service fostered a culture where most people felt they could speak up and their voice would be heard. Some were not sure if their concerns would be addressed.

The trust had a Freedom to Speak Up Guardian and a network of local Freedom to Speak Up ambassadors and champions. The trust’s Freedom to Speak Up Policy for the NHS gave staff information about different ways they could raise concerns and explained the steps involved in raising concerns through the Freedom to Speak Up process.

We observed Freedom to Speak Up posters in offices on inspection. Some staff told us they knew who their local champion was, and others told us there was an “open door” culture to raising concerns. Some told us they felt able to raise any concerns “without hesitation” although others said they felt their concerns would not be addressed.

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

Staff in the service could access support from staff networks. The staff networks were Black and Minority Ethnic (BME), Lived Experience, Women’s, Disability and LGBTQ+.In addition to providing support, the staff networks also provided the trust with advice and guidance on matters that affected their members, to help create a more equal workplace.

The trust had 256 Diversity in Recruitment Champions who sat on interview panels for more senior level job interviews. The trust told us champions contributed to the interview process and decision making as part of their commitment to tackling inequalities in under-representation of Black and ethnic minority staff at more senior levels.

The trust had a Flexible Working Policy that informed staff of their rights to request flexible working and the process to follow to do so. Several staff told us about their or colleagues’ flexible working arrangements. 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 services did have governance arrangements in place, but they were not working consistently or robustly. They did not deliver appropriate levels of oversight to provide knowledge and drive improvement.

Teams were meant to have local governance meetings, but records of these meetings showed that these had variable agendas and were not happening consistently across the directorates. This led to variation in how information was escalated and shared with teams to promote safety, effective treatment and promote improvement.

Work was taking place to improve the quality of information available about the delays being experienced by people using the health-based place of safety, however at the time of the inspection there was further progress needed. A digital dashboard was being embedded to provide oversight, but a record of Approved Mental Health Professional (AMHP) and Section 12 doctors attendance was not yet being captured to understand the reasons for delays. This meant it was not possible to clearly identify areas for improvement and monitor progress.

For delays in referrals to the home treatment teams, there were issues of data quality. There were gaps in the 4-hour data for urgent referrals. This meant it was hard to accurately monitor areas for improvement.

The trust recognised that there was insufficient oversight of breaches in the length of time people were spending in the health-based place of safety and the delivery of treatment without the legal framework to do so. They proposed strengthening the terms of reference of the directorate and trust wide Mental Health Law committees, but this had not yet happened at the time of the inspection.

Operational risk registers were sometimes out of date or incomplete. For example, there were 2 risks related to HBPoS in Southwark. A risk related to repeat ligature risk assessments on bathroom doors was added in 2023 and rated extreme. This did not have any action confirmed to mitigate the risk. A second risk related to an increase in the number of unapproved restrictive practices or restraint techniques used was added in 2022 and rated high. Data the trust initially sent us did not record any control or assurance in place for either risk. However, they later provided evidence to show actions had been identified to manage this risk and the trust approach to restrictive practice training had been changed since the risk was added.

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

The trust had close working relationships with other trusts and organisations that were part of Southwest London’s integrated care system (ICS), including voluntary organisations. Most staff told us about the close working they did as part of Southwest London ICS, including participating in the multi-agency safeguarding hub. Some managers and senior leaders told us they met monthly with the Integrated Care Board to focus on improving patient pathways.

Staff at all levels and in all directorates told us about the importance of partnership working with organisations and the wider community to deliver care and treatment. For example, some staff told us about the need to work closely with local acute hospitals to support patient flow through emergency departments. Several staff told us they liaised regularly with medical wards to gain updates on patients to plan for their care after discharge.

Some senior leaders told us they engaged regularly with external stakeholders, such as commissioners and Healthwatch, which helped them to meet the needs of their populations and share any necessary information about services.

The trust worked with primary care partners to support people who used services. There were 9 mental health practitioners based at GP surgeries in Southwark, Lewisham, Lambeth and Croydon, jointly funded by the local primary care network and the trust. These staff provided combined consultation, advice, triage and assessment function to people in primary care with mental health needs.

Most staff gave examples of other third sector organisations they worked with. For example, some staff told us about a local club house that provided a night sanctuary. Sometimes staff would meet people in the club house to support them. We observed care during which staff signposted people to local groups in the community, such as an art group.

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

The Southwark and Croydon HTTs had been accredited by the Royal College of Psychiatrists for meeting the standards of the Quality Network for Crisis Resolution and Home Treatment Teams. Home Treatment Accreditation Scheme.

The service had numerous quality improvement projects underway. This included the introduction of improvement huddles in home treatment teams to ensure oversight of improvement activities taking place in teams.

We observed one of the twice-weekly quality improvement meetings held in a home treatment team. The meeting was held in the office, which allowed open discussion and involvement from all staff. The flow and progress of quality improvement projects was discussed, as well as new initiatives, and successes were celebrated including improvements in patient survey responses.

As part of the trust’s aim to provide a clear and consistent offer across directorates, the service was actively involved in the trust’s Acute and Urgent Care Transformation work. Each directorate had dedicated quality improvement and project management professionals allocated to them to support the transformation. The transformation aimed to prevent avoidable emergency department attendances and admissions to hospital when people experienced a mental health crisis by better supporting people in the community. By April 2025, they had carried out reviews of home treatment teams, crisis assessment teams and mental health liaison and had plans to focus on how those teams worked together. The trust engaged with people who used services, carers, staff, partner organisations and voluntary, community and social enterprise groups to inform the transformation work.

The service had secured funding to carry out a project focused on Advance Choice Documents. Advance Choice Documents allow people with fluctuating mental illness to say, when they are well, what treatment they would like to have if they become ill in the future. The project aimed to reduce rates of Mental Health Act detention and racial inequality in experience and outcomes by ensuring friends, family and professionals know what people’s wishes are in advance.

Staf and managers told us about some of the improvement work their teams were involved in. For example, Croydon home treatment team (HTT), staff told us they were using artificial intelligence to analyse phone calls and care record notes to scan for key words.

In Lambeth HTT, they had created smaller sub-teams of staff overseen by a psychologist. Autistic people and those with complex trauma or additional needs were seen by the same sub-team as much as possible to help build relationships that could aid recovery. An away day had been booked to discuss feedback and carry out initial data analysis.