South London and Maudsley NHS Foundation Trust

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• Overview
• Kindness, compassion and dignity
• Treating people as individuals
• Independence, choice and control
• Responding to people’s immediate needs
• Workforce wellbeing and enablement

This means we looked for evidence that the service involved people and treated them with compassion, kindness, dignity and respect.

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

We found that improvements were needed as follows:

The staff engagement with people who use services was largely positive but we were also told and observed poor engagement. For example, we observed staff ignoring and not responding to requests from people who use services for support; and we heard about staff entering the rooms of patients without knocking on their door.

On some wards people who used the service did not have access to drinks and snacks and when these were requested, they had to wait a long time. There was not a clear rationale for why drinks and snacks could not be made available.

Staff reported feeling burnt out and many had experienced verbal and physical abuse from patients including racial abuse. This was reflected in the NHS staff survey results. Whilst the trust was working to improve staff wellbeing, staff were still expressing that they had a poor work experience.

There was evidence of positive practice. Care planning had improved and reflected patients’ individual needs and preferences. The trust was working to provide a more thoughtful and caring service for people who use services. For example, as part of a pilot, patients on Lucas Ward were given a welcome bundle which included herbal tea bags, aromatherapy oil, the activities timetable, sanitary products, toothpaste, and soap. Patients said this helped them feel welcomed and supported on admission. On a couple of wards volunteers with lived experience supported people using the service with recreational activities.

This service scored 55 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The evidence showed some shortfalls. Although feedback from patients was that most staff were kind and caring, they also reported a variation how engaged some staff were and gave some examples of not feeling respected and not always having their privacy upheld.

We spoke with 57 patients and 16 carers.

The interactions we observed were mostly respectful, supportive and staff treated patients with dignity and kindness. Most patients reported that the staff were kind and caring, treated them well and acted appropriately towards them in a respectful manner. Most patients spoke highly of the support and kindness from staff across the trust.

While the service monitored patient’s and carer feedback on how they are treated throughout the year, patients highlighted some areas for improvement. Some patients from across the wards told us they did not always receive information about their ward round or know who they had spoken to during their meeting. Some patients said that staff interaction varied, and they sometimes felt talked down to or ignored. Some patients on Jim Birley Unit and Croydon PICU said they felt they were sometimes threatened with rapid tranquilisation if they were not compliant. Review of the trust’s rapid‑tranquillisation monitoring showed these wards were not outliers in their use of rapid tranquillisation. We heard examples of patients being physically assaulted by other patients and possessions going missing, and people say they did not always feel safe on the wards. On Gresham 1 Ward, patients reported feeling ignored by some staff and experiencing poor engagement. During our observations on this ward, several patients attempted to interact with staff, but staff did not respond. On Jim Birley Unit we saw patients knocking on the staff office door not being attended to. Some patients told us that the staff were not always respectful of their privacy, for example, by not knocking before entering their bedrooms. This is a breach of regulation 10 Dignity and respect.

Eleven of the 16 carers we spoke with made positive comments about their experiences with the trust. They said staff were committed and helpful, they felt well informed about their relatives’ care and treatment, and they believed their relatives’ health had improved. Carers also told us they received newsletters and that there was a holistic approach to care. Four carers said their thought their relatives were safe, and some described the transition to community care as ‘quick and seamless.’

However, five carers described negative experiences. For example, one carer said patients were not provided with their gluten-free meal option, and another told us they were not always invited to meetings. One carer also said that their relative had not improved and described their experience as a ‘revolving door,’ as the patient kept being readmitted to hospital. Some carers also told us that staff lacked understanding of patients with autism.

On Jim Birley Unit, we saw physical health observations being undertaken in the lounge area, impacting on the patient’s privacy.
 

Staff introduced patients to the wards and provided welcome packs to patients on admission, although not all patients we spoke with recalled receiving one. Welcome packs included information such as what to expect from the team, search and mobile phone policies, complaints and compliments processes, and advocacy services. As part of a pilot, patients on Lucas Ward were given a welcome bundle which included herbal teabags, aromatherapy oil, the activities timetable, sanitary products, toothpaste, and soap. Patients said this helped them feel welcomed and supported on admission and promoted a positive start to their care experience.

Staff worked to ensure patients understood their care and treatment. Multidisciplinary staff met with patients weekly to discuss their support and treatment. Staff could produce easy-read care plans and documents and translations into other languages, for those who needed them.
The patient experience audit covering June 2024 to June 2025 showed that most patients had a copy of their care plans and were involved in decisions about their care and treatment. However, at the time of the inspection some patients gave a mixed picture of being involved in their individual care plans or understanding the way forward in their treatment. Some patients did not know what a care plan was referring to.

We saw how patients were supported with reasonable adjustments to the environment to meet their individual needs. In most care records, it was clear that patients’ views were included in their care plans using their own words. Care plans enabled patients to describe themselves and their thoughts.

Relatives and carers were invited to attend ward rounds and discharge planning meetings where patients had given consent for them to attend. They could do so in person or using video-conferencing facilities. There was a carers lead for all the wards we visited, with regular meetings arranged,and appropriate support provided to relatives or carers of patients on the wards.

Patients had access to spiritual, religious and cultural support.

The trust recognised and celebrated the contributions of LGBTQ staff and recognised the historical complexities of LGBTQ individuals experience in accessing and receiving healthcare, but could have done more on the wards to inform and support patients. We observed that staff did not always use the preferred pronoun or name of patients, even though this information was clearly displayed on a whiteboard on their door. We did see that some wards information displayed on the noticeboard about advisory and support services to help LGBTQ+ patients access external support.
 

The evidence showed a good standard. The service promoted people’s independence, so they knew their rights and had choice and control over their own care, treatment and wellbeing.

Patients were able to give feedback on the service and their treatment, and staff supported them to do so. We observed community meetings which were patient-focused and encouraged active involvement. These were held weekly on all wards, where patients met with staff to discuss ward updates and provide feedback. Minutes from community meetings were displayed on ward noticeboards for patients to review. We saw limited information available to patients about the follow-up of actions from these meetings.

Care plans generally reflected patients’ assessed needs, were personalised, holistic and recovery oriented.

Not all patients were clear about how to make a complaint if they were unhappy about the service, although several said that they would know how to find out if needed. All the wards we visited had complaint posters on the noticeboard. On Gresham 1 ward, the ward manager did a weekly ‘complaints and compliments’ surgery every Friday from 3 pm to 4 pm.

Staff ensured that patients had access to independent advocates.

Patients across all wards noted that there were sometimes blocks in the flow of information from doctors to nurses, and then to patients, which could lead to frustrations.

Volunteers with lived experience attended the wards three times a week. They supported patients, took part in ward recreational activities with patients, such as knitting, and worked in collaboration with the occupational therapist on Virginia Woolf and Wharton wards. They could also support patients in ward rounds, if the patient wanted.

The service listened to and understood people’s needs, views and wishes. The service responded to these and attempted to minimise any discomfort, concern, or distress.

Staff responded to people’s needs in the moment and acted to minimise any discomfort, concern or distress. For example, the inpatient areas in Southwark do not have air conditioning units, and on particularly hot days, patients were provided with ice lollies and other refreshments to minimise discomfort.

Most patients could access a ward garden easily. However, on Jim Birley, the ward garden was located 2 floors below and patients had to be escorted by staff. Patients told us that they couldn’t always access the garden when they wanted.

Some patients gave mixed feedback about staff support, indicating that some staff were more helpful than others. They sometimes felt that there were not enough staff on duty to give them meaningful support with their mental health. They often had to wait a long time for a staff member to be free.

On Lucas ward, hot and cold water were left out, and patients could help themselves to drinks. Patients on Jim Birley Unit and Eileen Skellern 1 did not have direct access to drinks and snacks, and requested these from staff. Some patients reported delays in staff providing them.
 

The evidence showed some shortfalls. Whilst staff said they were well supported by their immediate team and line managers, they reported challenging levels of acuity, burnout, and concerns about risk of injury, to themselves and to patients.

Ward managers told us that staff were supported following incidents or when they had sustained injuries at work. Support included maintaining regular contact, encouraging staff to involve the police where appropriate, and arranging phased returns to work that took account of individual circumstances.

Staff experienced racial abuse from some patients and we witnessed this take place during the inspection. Staff were aware of how to seek support from managers when this happened and were encouraged to report this. Although the trust had systems in place to report racial abuse towards staff, more could be done to make it clear how the trust was proactively addressing and preventing this at ward level.

The trust staff took part in the national NHS staff survey for 2024. Thirty-nine per cent of staff responded to the 2024 survey. Fifty-seven per cent of staff said that in the last three months they had come to work despite not feeling well enough to perform their duties, compared with 45% in 2023. In addition, 42% of respondents reported feeling unwell in the last 12 months because of work-related stress. However, the low response rate limited the representativeness of the findings, and the service should take steps to improve staff survey engagement to ensure feedback is more representative.

The trust was aware of the wellbeing needs of their staff and several wards had wellbeing projects in place. In Croydon PICU, there was a quality improvement (QI) project for nurses around creating psychological safety and spaces where nurses felt able to raise concerns and ask questions without fear of negative consequences. This was in addition to psychologist-led reflective practice sessions. Staff told us the team had an away day in March 2025, which has made a difference in staff morale and engagement.

Most staff we spoke with spoke positively about the support provided within their individual teams and opportunities available for training and development.