South London and Maudsley NHS Foundation Trust

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• 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

This means we looked for evidence that the service met people’s needs.

At our last comprehensive assessment, we rated the key question good.

At this assessment, the rating remained good.

This meant that people’s needs were met through effective organisation and delivery of care. We found many examples of the ward staff supporting people who use services to receive services that responded to their individual needs.

This service scored 75 (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 a good standard. The service made sure people were at the centre of their care and treatment choices and decided, in partnership with them, how to respond to any relevant changes in their needs.

Staff worked with patients to develop individual care plans, which were reviewed regularly through multidisciplinary team (MDT) discussions and updated as required. This ensured that care remained person-centred, responsive to patients’ changing needs, and supported safe and effective treatment. We reviewed a sample of data from the trust’s patient experience audits. Overall, patients from 13 of 14 wards responded positively to completing a care plan with their primary nurse and meeting regularly with the MDT. Most patients reported that they were involved in decisions about their care and treatment.

Patients were able to provide feedback on the service, raise concerns and share ideas for improvement through the weekly community meeting.

The wards were able to support patients with disabilities and those with communication or other specific needs. For example, there was lift access to the wards, and some rooms had additional space to improve wheelchair accessibility. Easy-read information was available, and managers ensured that staff and patients could access interpreters or signers when required.

The service provided a variety of food to meet the dietary and cultural needs of individual patients, for example, halal and vegan options.

Patients could keep possessions in their bedrooms or secure lockers. Patients could use mobile phones to make phone calls in private and could also access a ward phone.

The trust had processes in place to oversee patient flow and bed management. Bed management meetings took place to determine availability of beds for new admissions and to support the appropriate discharge of patient who were ready for this. Lucas Ward opened in March 2024 in response to a need for further inpatient beds at the trust.

Staff said that delayed discharges were often due to accommodation issues, where patients were waiting for suitable accommodation.

Staff worked in partnership with external organisations to support patients to engage in activities within the community.

Staff supported patients to stay in contact with family members, including visits to the service, and involvement in relevant meetings about their care.

Staff supported patients to access their chosen place of worship within the community.

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

Staff provided patients with relevant information about the wards. Staff were able to provide easy-read care plans and documents, and translations into other languages, for those who needed this.

Each of the wards had information boards available for patients and carers, with important information about the ward and physical and mental health conditions, including contact details for complaints, advocacy services and the Care Quality Commission. We observed a weekly and monthly timetable of activities, which were also placed on the noticeboards, so patients are aware of what activities to expect daily.

Four of the 16 carers we spoke with told us they were provided with information about the carers’ group, which they found very useful and said helped them feel less isolated. They also told us they were often invited to team meetings and to attend Family Anonymous, which they described as ‘enormously helpful.’ The Jim Birley Unit had a quality improvement project to enhance communication between staff, patients and families, reducing delays and improving patient experience.

Overall, most carers said they were supported by staff, where appropriate, to attend ward rounds. This helped families feel included in care planning and decision-making about their relatives’ care and treatment. These initiatives supported carer involvement and promoted a sense of partnership with the service.

The evidence showed a good standard. The service made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. They involved people in decisions about their care and told them what had changed as a result.

We reviewed a sample of 38 complaints across the directorates, of which 35 had been concluded and three were ongoing. Fifteen complaints were not upheld, 19 contained concerns that were partially upheld, and one complaint was fully upheld. The complaint responses we reviewed were detailed, included clear outcomes, and offered apologies where appropriate, demonstrating a responsive approach to patient concerns. Complaints included staff attitude, disagreement with medication, and items going missing.

Lambeth was involved in a quality improvement project on the management of complaints, including the time taken to complete responses and reducing the overall number of complaints.

The service was accessible to patients who needed inpatient care. At the time of inspection, there was a lot of pressure on the wider mental health system, meaning some patients waited to access an inpatient bed. The trust system of bed management had an oversight of and monitored delays.

The wards had facilities to support patients with mobility needs, including wheelchair users.

The trust provided patients with food to meet their dietary requirements. Patients across the wards were generally satisfied with the quality and quantity of food.

On ES1 and Gresham 1, an autistic patient said that staff made a reasonable adjustment, making the effort to provide them with a separate individual community meeting, as they were unable to join the communal meeting. They were also provided with noise-cancelling headphones and a specific cup type to meet their needs.

Staff undertook training in equality and diversity, and managers were clear about the need to ensure that people most likely to experience inequality had the best outcomes possible.

The trust had policies in place regarding equality and diversity, and staff understood people’s right to receive care and support that met their individual needs.

The trust was one of the pilot sites that worked with NHS England to develop the Patient and Carer Race Equality Framework (PCREF). This is a mandatory framework that aims to support providers to become actively anti-racist organisations and reduce racial disparity in the access, experience and outcomes that Black communities face in mental health services. This involved engaging with communities and supporting services to gather and embed the voices of people with lived experience. The trust had embedded PCREF into its assurance structures, its five year strategy and collected data around set metrics. Examples of what information the trust collected in order to better identify and then change disparity of experience was the use of MHA detention, the use of seclusion and restraint and the used of medication for Black people with a diagnosis of psychotic spectrum disorder. There was an action plan in place for April 2025 to March 2026 to develop this work even more.

Staff planned patients’ discharge and involved care managers and coordinators. Community care coordinators were invited to all ward rounds, either in person or via video conferencing facilities. We observed multidisciplinary team meetings which including external partners such as social workers, housing services, and discharge coordinators. We saw staff assessed patients’ need for coordinated care to ensure patients’ safe and timely transition out of the hospital. This collaborative approach supported continuity of care and helped reduce delays in discharge.

Staff ensured relevant healthcare professionals and other relevant bodies were involved in planning the care and treatment of people with complex needs.