South London and Maudsley NHS Foundation Trust

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• 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

This means we looked for evidence that people were protected from abuse and avoidable harm.

At our last inspection we rated this key question good. At this inspection the rating has changed to requires improvement. The service was in breach of regulations in relation to safe care and treatment.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

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.

Staff we spoke with knew what incidents were and how to report them in line with the trust policy. Incident reporting was part of the local induction, which 100% of staff had completed. During the 6 months before our inspection, total of 465 incidents were reported within the service. No incidents reported during that eriod were classed as serious or resulted in long-term harm. We reviewed a sample of 6 incident records. The records demonstrated that staff recorded appropriate level of detail, actions and learning from the incident. Safeguarding issues were identified appropriately and necessary actions taken. Staff discussed incidents and lessons learnt in a number of forums, including supervision, team meetings, daily huddles, handovers, four steps to safety (the trust’s system for safer care) and reflective practice sessions led by a dedicated consultant psychotherapist. Blue Light bulletins were disseminated to all staff to share rapid learning from incidents trustwide. We saw evidence that changes were implemented as a direct result of learning from safety incidents. For example, hot water temperature had been adjusted and security procedures overhauled across the unit based on learning from past incidents. We also heard that incidents used to happen frequently during mealtimes, and as a result, staff changed the serving system. Patients and carers were able to raise concerns, provide and receive feedback on issues that concerned them through community meetings, patient representative meetings and the Service User and Carers Advisory Group. Patients participated in the Reducing Restrictive Practice and Security meetings, the minutes of which demonstrated their active involvement. Carers we spoke with said that staff responded to their relatives’ safety concerns promptly. Staff understood the duty of candour and carried out after action reviews (AAR). The learning from these was shared and discussed at clinical governance meetings. For example, an AAR was completed following a medication-related incident and a restraint incident. The service had embedded the Patient Safety Incident Response Framework (PSIRF), the NHS framework aimed at learning from incidents and improving patient safety. Leaders told us that the adoption of PSIRF had contributed to improved learning and a more inclusive safety culture. For example, daily incident huddles helped identify any staff or patients who needed support following incidents. There was a post-incident protocol in place, with a senior leader allocated to provide follow up. The service promoted a restorative justice approach, supported by a dedicated restorative justice practitioner and trained staff. This process aimed to support patients to repair relationships with those impacted by harm. This approach was also used in responding to incidents between patients and patients and staff. Staff said that verbal aggression was a common type of incident but thought these were managed well overall, due to the strong focus on relational security. Staff received support and debriefs following incidents and could access the employer’s wellbeing resources for additional support. A staff member told us they felt well-supported and that colleagues routinely checked in on each other’s wellbeing. Managers included patients in discussions of verbal abuse incidents. We also heard that the trust actively encouraged and supported staff in reporting any incidents of verbal or physical abuse to the police.

Staff worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The service’s referral and admission processes ensured that all essential information about the patient was received to determine if the patient’s needs could safely be met. Patients were admitted under agreed criteria from other forensic services, criminal justice settings and inpatient mental health wards. Male patients were normally first admitted to Norbury (clinical decision unit), and all female patients to Spring Ward (female end-to-end ward).

Patients were admitted to wards near their home areas. The service was part of the South London Partnership (SLP), a partnership of 3 neighbouring mental health trusts. Staff we spoke with were positive about the role of SLP in supporting patients’ regular contact with family, friends and their local communities.

Staff regularly discussed and monitored referrals, admissions and discharges. We attended a patient flow meeting. Other attendees included representatives from NHS and independent healthcare providers who reviewed patient flow and waiting lists across the local network. A single point of access was used to assist with streamlining referrals. The meeting demonstrated a collaborative cross-organisational approach, where potential transfers within the network were explored to balance capacity and manage acuity.

Staff involved all the necessary health and social care services to ensure patients had continuity of safe care, both within the service and post-discharge. Staff ensured patients had regular access to primary and secondary care, dentists, chiropodists, podiatrists and physiotherapists. Staff worked closely with criminal justice and community mental health teams and involved care coordinators in ward rounds. Upon discharge, patients received a follow-up consisting of 3 sessions involving the patient and the receiving team.

Patients could be discharged into the community and other services. Male patients could be discharged to other wards within the unit such as Brook or Effra (assertive rehabilitation wards) or Chaffinch (pre-discharge ward).

Active discharge planning was clearly documented and evident in the care records we reviewed. Staff involved patients and relevant stakeholders and demonstrated a multi-agency approach to managing safe transition into the community.

Staff supported patients to prepare for discharge, once clinically suitable. We heard that there could be challenges due to circumstances outside of the provider’s control in discharging patients who required supported accommodation, due to its availability and funding issues. Most patients we spoke with said staff kept them up-to-date on their discharge plans. For example, one patient told us they were nearing discharge and were going on day visits with support from staff. Another said: “Staff talk to me about my future at a supported living home”. Carers told us they knew about their relatives’ discharge plans, where applicable, and that staff kept them informed. One said: “There are plans to invite me to the discharge meeting. Staff have talked to me about how it will work, it was very reassuring”.

Staff worked with patients and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving patients’ lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. Staff shared concerns quickly and appropriately.

The trust had policies on safeguarding adults and children and staff knew how to identify safeguarding concerns. Over 90% of staff had completed Safeguarding Adults and Children training and 100% Prevent (training aimed at safeguarding people from the risk of radicalisation and extremism).

The service had a safeguarding lead who was a qualified social worker. Each ward was supported by a dedicated social worker. Staff spoke positively about the role of the social work team. Staff said they were clear about the safeguarding procedures and there were regular discussions and training in this area. The safeguarding lead had a close oversight of incident notifications and open enquiries. Safeguarding was discussed regularly at ward, directorate and local network level.

Staff knew how to make a safeguarding alert and did so when required. In the incident records we reviewed, safeguarding was flagged appropriately and necessary actions were outlined. If any allegations involved staff members, managers followed the position of trust process. Staff were aware of the risks specific to their patient group and shared examples of recent referrals. However, on Chaffinch Ward, a safeguarding alert had not been raised following 2 recent disclosures made by a patient. Following our feedback, the safeguarding lead ensured that a referral was made promptly.

Staff worked in partnership with other agencies such as the local authorities and police. For example, there were regular case review meetings with the police liaison officer.

Staff could give examples of protecting patients from harassment and discrimination, including those with protected characteristics under the Equality Act 2010. For example, staff on Spring Ward told us about supporting a transgender patient to ensure their safety and wellbeing, as well as that of the other patients.

Visiting facilities were located away from the ward environment and were available for people to visit their relatives safely.

Staff regularly reviewed and updated blanket restrictions in line with the trust procedure and added those to the blanket restriction register. This process considered the impact on individuals with protected characteristics. There were some restrictions in place on the wards, which were proportionate to maintain a healthy and safe environment. For example, there was a restriction on internet access and some sharp items. Some restrictions were patient-specific, based on individual risk assessments. Most patients we spoke with said they understood and agreed with the reasons for restrictions. However, we found some inconsistencies across the wards. On Thames Ward patients could only have decaffeinated coffee, although regular coffee was provided on the other wards. Minutes of community meetings indicated that sugar was recently restricted on Brook Ward, and that patients were not allowed to eat in their bedrooms on Norbury Ward.

Staff did not always work well with patients to understand and manage risks. Staff did not always provide care to meet patients’ needs that was safe, supportive and enabled patients to do the things that mattered to them.

We reviewed risk assessments and risk management plans in 18 care and treatment records across all 7 wards. On admission, patients received a timely risk screening and a full physical health assessment by GPs and dentists, clearly documented in the records. Assessments were comprehensive, regularly reviewed and discussed within the wider multidisciplinary team (MDT), demonstrating a structured and joined-up approach to managing risk. Risk assessments were updated to reflect the most recent risk events. Trained staff completed Historical Clinical Risk Management-20 (HCR-20) assessments for all patients. HCR-20 is a structured tool used to assess risk factors for violence.

Staff carried out different levels of observations and reviewed these based on individual need and risk. However, the records we reviewed indicated that observations had not been carried out and documented in line with the trust observation and engagement policy. For 3 patients on Norbury and Waddon wards, the intermittent observation records lacked appropriate detail. Additionally, we were concerned that a small sample of observation records had been pre-signed in advance. Staff told us that these issues had been previously identified in audits. We escalated our concerns to the leaders, who shared an immediate action plan to address them.

The use of restraint within the service was rare. Total of 48 incidents of restrictive practice were reported in the 6 months prior to our inspection. There were no restraints in the prone position, and no use of long-term segregation. Most patients we spoke with confirmed that they had never been restrained during their admission. Patient representatives actively participated in initiatives, training and research aimed at reducing restrictive practices. The service had a strong focus on relational security and staff we spoke with were proud of this culture. Staff completed Seni Lewis training in the least restrictive practice, developed by the trust and named after a patient who died in 2010 after an incident of restraint. Over 92% of staff had completed this training at the level in line with their role. However, we reviewed a recent incident of seclusion on Norbury Ward. We found that the 2-hourly nursing reviews of the secluded patient had not been completed in line with the protocol and the Mental Health Act 1983 Code of Practice. Following our feedback and after conducting an internal investigation, leaders provided assurance that audits in this area would be strengthened.

Staff involved patients in care planning and risk assessment, with evidence of patient voice in most records. Most patients told us they felt supported to understand the risks and keep themselves safe. They said they were involved in their care and treatment and were offered a copy of their care plan. There was evidence of patient involvement in their ward rounds and care programme approach (CPA) meetings. A quality improvement project to involve patients in chairing their own CPAs and medication reviews was ongoing to promote autonomy and engagement. For example, patients on Brook Ward had started chairing their CPAs.

Carers said their relatives reported feeling safe on the wards. With their relatives’ consent, carers attended CPAs, MDT meetings, medication and care plan reviews and discharge meetings, which they could join online. Some carers shared examples of providing input at these, which staff listened to and took action. One carer said: “Staff listen and involve us”.

Staff communicated with patients so they understood their care and treatment. Staff arranged interpreters for patients and carers and provided information in accessible formats if required. For example, staff on Spring Ward told us about using a poster with words and images to communicate with an autistic patient at times when the patient did not feel like talking.

Staff described balanced and proportionate approaches to managing risks. Both staff and patients shared their concerns about illicit substance use as a recent challenge on the wards. Staff were working to reduce this risk. Most patients we spoke with understood and agreed with procedures such as drug screening, searches and restrictions on ordering certain items. Staff actively monitored patient dynamics to identify individuals who may be vulnerable to bringing or accepting drugs. There was support on offer for patients, including weekly cannabis clinics, mutual aid groups and education on the legal implications of drug use.

Staff enabled patients to give feedback through various methods including surveys and meetings. The meetings we attended and minutes we reviewed showed that patients participated confidently and raised queries constructively. We spoke with 2 patient representatives who told us about their role in ensuring that patient voice and feedback was heard.

Staff ensured that patients could access advocacy in line with their rights under the Mental Health Act. The service was implementing an opt out system for advocacy, meaning that every patient would receive advocate’s support automatically, but could opt out if they did not want this. Advocates’ contact details were clearly displayed on the wards. Patients we spoke with knew about the advocacy service and who the advocate was.

Staff detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Staff carried out regular environmental and safety audits and completed relevant training, with 97% up-to-date with Fire Safety Awareness, 94% with Fire Warden and 100% with Health and Safety training. There were daily security checks and safety huddles. There were robust fire safety management systems, with up-to-date records of all appropriate checks maintained. Patients with additional needs had personal emergency evacuation plans (PEEPs) which were regularly updated and easily accessible in the event of emergency.

The ward environment was calm, light and spacious. On most wards, the layout allowed staff to observe most of the communal areas, with mitigations in place for the blind spots. However, on Chaffinch Ward there were limited sightlines from the nursing station and no CCTV. We also shared our concerns about several potential security risks in the outdoor areas of this ward. Leaders provided assurance that these would be addressed immediately.

Overall, staff managed ligature risks well and there were no blanket restrictions in this area. Where no risks have been identified for individual patients, they could use items with cables up to a certain length. Staff carried out regular audits and had access to ward-specific risk assessments. Staff were aware of potential ligature anchor points and supervised these areas. Staff had ensured the care environment was the least restrictive, however on Norbury and Waddon wards we identified 2 potential ligature risks in areas with unsupervised access. Following our feedback, staff took prompt action to remove those.

Patients were able to discuss their concerns about the ward environment in weekly community meetings. For example, on Chaffinch Ward patients raised the air conditioning being out of order, and staff ordered electric fans until it could be repaired. Patients on Effra Ward raised hot water not running, and maintenance staff attended promptly to fix this.

The service admitted male and female patients and each ward provided single sex accommodation only. Patients could request to work with male or female staff, if preferred. Staff followed the trust policy to support transgender patients safely.

Patients had access to their rooms throughout the day and had personalised their bedrooms. Each room was equipped with a nurse call system and ensuite bathrooms with anti-ligature fixtures. All wards had access to well-maintained gardens with gym equipment. However, access to outdoor areas required staff supervision and patients on some wards told us this could be an issue due to staff availability. Outdoor access was raised in the community meeting we attended on Effra Ward. We saw limited garden use during our site visit.

A dedicated team oversaw all aspects of security within the service and was easily accessible to staff and patients. Ward entrances were secured with an airlock system to prevent unauthorised access or absconding. Each ward had an integrated alarm system that directed staff appropriately during incidents and all staff carried personal alarms. The alarm system was tested weekly to ensure it was in working order. However, on Chaffinch Ward we observed a staff member with keys clipped to a belt without secure fastening, presenting a potential security concern. We raised this with the security team, who responded immediately by replacing the key holders.

Seclusion facilities were located on Norbury and Spring wards and were used by all wards for male and female patients respectively. Seclusion rooms were well-ventilated, allowed clear observation and two-way communication. While in seclusion, patients had access to food and drinks, a clock, and toilet and shower facilities. The use of seclusion was rare due to the effective use of de-escalation and relational security.

Sensory provision was available on some wards. Spring Ward had a sensory room with a light box and padded floor which patients could use when they wished. On Chaffinch Ward, the quiet room was equipped with sensory tools, offering a calming environment for patients requiring reduced stimulation. There was no dedicated sensory space on Effra, Brook, Thames and Norbury wards, although they had quiet rooms. On Brook Ward, staff had created a spirituality room with a massage chair and religious materials available. The patient using this room during our visit told us he “really liked it" as an addition to the ward.

Clinic rooms were fully equipped with resuscitation equipment. Emergency medicines including oxygen were appropriately stored and monitored regularly to ensure they were easily accessible. Staff monitored room and fridge temperatures appropriately.

Carers’ feedback about the hospital environment was positive. They described it as safe, welcoming and clean. One said: “It is really made to make people value themselves”.

Staff were qualified, skilled and experienced. They received effective support, supervision and training and worked together effectively. However, temporary staff shortages within some teams impacted care provision and patient experience.

At the time of our inspection, there were vacancies on 5 out of the 7 wards. Norbury and Spring wards were fully established. Chaffinch Ward had the highest number of vacancies at 7 WTE, equating to 23% of the ward establishment. This was followed by 12% vacancy rate on Thames Ward, 8% on Waddon, 6% on Effra and 4% on Brook. The highest vacancy rate across all the wards was for Band 3 Support Workers, at 6.4 WTE, although 3 had been appointed and going through recruitment checks.

In the 6 months prior to our inspection, the average staff turnover was around 7% and sickness absence around 5%.

Managers had calculated the number and grade of nursing and support staff required and reviewed the safe staffing matrix regularly. During the 6 months preceding our inspection, 32 shifts (1.5%) were short by one or more staff member across all wards. During the same period, 28 staffing incidents were reported, mainly due to clinical staff shortages. Staff and leaders attended daily staffing huddles to review and respond to any staffing gaps identified for the following 24-72 hours. Managers could deploy bank staff through the trust’s approved provider, and there was no agency staff use.

At the time of our visit, there were staff shortages within Occupational Therapy (OT) and Activity Practitioner (AP) department. The team was 3 OT and 3 AP short, and although the vacancies were in various recruitment stages, this had impacted on the availability of ward-based provision. OT and AP shortages affected Norbury, Thames and Effra wards. Patients on those wards told us they felt bored and there was not much to do.Some patients also reported limited access to fresh air. One patient said he wanted to use the kitchen more to cook for himself, but there was not enough staff to support this. Another said: “Ward is so boring, I want to join in more, but activity choice isn’t great”. Some patients were concerned that the perceived boredom contributed to increased drug activity on the wards. Staff also spoke about limited activities on some wards and told us that other MDT staff stepped in to help, with some support from patient representatives. Shortly prior to our visit, patients on Effra Ward made a group complaint citing ongoing lack of OT and AP. Following the complaint, the leaders added the OT and AP shortages to the risk register. Leaders updated us that managers were attending community meetings to discuss and agree interim solutions.Since our inspection, we heard that full staffing had been achieved across the 3 affected wards.

On Norbury Ward, access to individual psychology sessions was more limited at the time of our inspection due to staff maternity leave. However a dedicated assistant psychologist and a lead psychologist provided the required psychology input for the ward, and dedicated family therapy provision was available.

Most patients told us that staff were always available when they needed support and they had regular one-to-one sessions with their named nurses. Staff views were more mixed, with some saying the wards were adequately staffed, whilst others thought that staffing could be improved. Some said this depended on the acuity levels on the wards and numbers of staff required to facilitate escorted leave.

We observed staff always present in the communal areas of all wards. Although physical interventions were rarely used, there were enough trained staff to carry these out safely. There was adequate medical cover, with an on-call system in place, and a duty doctor could attend quickly in an emergency.

Staff participated in regular training, appraisal and supervision and leaders monitored the completion rates. These were consistently high, with 95% of staff up-to-date with mandatory training. The training and induction were tailored for the patient group using the service. The induction programmes were tailored to the medium and secure settings, and 100% of new starters had completed their induction. Over 92% of staff were up-to-date with supervision and 100% with appraisal. Staff had access to additional supervision formats, such as clinical supervision and reflective practice sessions. We spoke with a student nurse undertaking their placement within the service, who shared positive feedback about the support from their assessor and the rest of the team.

The service followed the trust recruitment policy, with robust systems for safe recruitment of staff. These included criminal record and right to work checks, and where relevant, evidence of continued professional registration. Managers and HR monitored the completion and renewals of these.

Staff assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The care environment on all the wards was visibly clean, well-maintained and appropriately furnished. The service had an external cleaning contractor who completed the relevant records. However, a recent cleaning audit on Spring Ward identified some areas as “badly cleaned”. We could not establish if this had been addressed, because the cleaning contractor’s records were not accessible to staff. We discussed this with the managers, who told us they would follow this up.

Patients were able to give feedback on the environment and raise any issues in weekly community meetings.

Over 96% of staff had completed the mandatory Infection Control training. Staff followed the trust policy in adhering to infection control principles, including handwashing, and used personal protective equipment. Staff completed regular hand hygiene and decontamination audits on each ward. Staff maintained clinical equipment well, cleaning it regularly and after each use.

Staff carried out appropriate safety checks to detect and prevent the spread of infections. Regular Legionella risk assessments and monitoring of the water systems took place, with up-to-date records kept.

Staff made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

Medicines were managed safely. There were systems for ordering, administering and monitoring of medicines. A ward pharmacist contributed to the management of physical health monitoring and medication oversight. Staff we spoke with described pharmacy support as “excellent”. Staff were trained and deemed competent before they administered medicines.

Medicines were safely stored and records appropriately kept. The service kept prescription stationery securely and monitored its use. Medicines administration records were recorded comprehensively and accurately on the provider’s electronic system.

The service carried out regular medicines audits to ensure prescribing was in line with best practice guidelines for safe prescribing. Staff ensured that patients were taking their medicines, for example via stock counts.

Medicines-related incidents were investigated properly, with appropriate action plans, and there were processes to ensure staff learned from these incidents to prevent them occurring again.

Most patients and carers said staff had provided enough information about theirs or their relatives’ medicines. One carer told us: “Staff had a conversation with me and my son about increasing his medication. Neither of us wanted that, they listened to us and it didn’t happen.” Patients received their medicines safely, consistently and as prescribed. We reviewed 16 patients’ medicines and found no discrepancies in the recording of medicines administered.

The use of rapid tranquilisation (RT) was minimal. However, for 1 patient in seclusion on Norbury Ward, post-RT physical health monitoring had not been accurately recorded in line with the provider’s policy and best practice. Some of the observations had been completed but not reflected in the notes, and in another instance, it was not clear if the necessary monitoring had taken place. Leaders responded to our findings and initiated an immediate policy review to reflect the specific requirements for post-RT monitoring in seclusion.

Some high dose antipsychotics were prescribed, with monitoring arrangements in place to ensure they remained safe and effective for the patient. This was also the case for patients prescribed clozapine.

Consent to treatment authorisations were mostly up-to-date and reflected the patients’ needs.

We saw several instances of where patients were prescribed PRN (as required) medicines. There were associated PRN protocols in place to manage these safely.

Staff carried out physical health monitoring checks to ensure the patients were physically well and able to tolerate the prescribed medicines. However, we found this was not always consistently applied across the wards we visited. For example, in care records on Norbury and Chaffinch wards we found that NEWS2 observations were not always completed in line with the prescribed frequency.