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

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

At our last comprehensive inspection, we rated this key question as requires improvement. At this inspection, the rating has remained requires improvement.

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.

We found that improvements were needed as follows:

Staff were not always completing accurate records following incidents of restraint. This meant it was not possible to ensure that restraint was carried out safely and appropriately.

Patients were experiencing assaults from other patients but were not included in debriefs where appropriate.

There were ongoing delays in reviewing patient safety incidents to support the learning from themes. This was an area for improvement at the previous inspection. Whilst this had improved, there was more to do.

Some wards had low completion of mandatory adult and children’s safeguarding training. On one ward three potential safeguarding concerns had not been identified and addressed in line with trust procedures. The trust resolved this during the inspection.

Records of therapeutic observations indicated that these were taking place at regular rather than intermittent time periods. Also, some records were not completed fully which could impact the safety of the observations taking place.

Records of seclusion checks indicated that medical and nursing checks were not always happening within the necessary timescales.

At the time of the inspection there were a high level of incidents where patients and staff were being harmed on Wharton ward (five in one day). In response to concerns raised by the inspectors the trust reviewed and increased the staffing on the ward. Whilst there were systems for staff to report on the acuity of people using the service and review staffing levels, staff said that these did not always ensure the appropriate levels of staffing.

Some ‘as required’ (PRN) medicines were administered without a documented reason for why this was prescribed.

There was evidence of good practice. The use of restraint across the wards had reduced. The assessment and management of risk had improved. The trust was piloting a quality improvement project ‘Home before lunch’ for adult inpatient wards to improve the discharge process.

This service scored 53 (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 areas of improvement were needed.

Staff knew what incidents to report and how to use the system to report them.

The trust’s monthly data for incidents of prone restraint from April 2021 to August 2025 showed that the number of prone restraints had reduced significantly over the last four years. For most incidents we reviewed, we saw that staff completed reports when necessary and included information about the incident, actions taken in response and learning to inform and improve care and treatment. However, between 1 January 2025 and June 2025, restraint was reported in 9 of the 11 wards. Of these, 4 wards reported the use of prone restraint. When considering only the 9 wards that reported restraint, 4 used prone restraint. Staff did not always record full details of restraint incidents in patients’ records, including information about the specific holds used. Staff had not included all necessary details in line with trust policy. For example, the position of the patient and each staff member’s position and involvement in the intervention. This meant it would not be possible for those reviewing the incident form to determine if the use of force was appropriate, effective and in line with training and requirements. This was a breach of regulation 12 ‘Safe care and treatment’

After incidents, patient debriefs were not always recorded in patient records and most patients we spoke with did not remember receiving these. Staff confirmed that they received debriefs. audit data showed that debriefs had been completed in line with policy, based on the documentation reviewed.

Incident reports were routinely reviewed and discussed during the daily incidents huddle, and while some incidents were awaiting final approval on the system, such as those noted on the risk register for Gresham 1 ward as part of the ward closure process, the service had clear oversight arrangements in place to ensure these were appropriately followed up and closed following risk review.

Staff we spoke with said that they discussed learning from incidents and near misses at handover meetings and business meetings. The types of incidents reported included violence and aggression, medication incidents, safeguarding and infection control. The staff were able to provide examples of learning from incidents, including incidents of violence and self-harm. Learning included ensuring they were rigorous regarding searching for contraband items. We saw evidence that managers discussed patient safety incident reviews in governance meetings.

The trust carried out investigations after serious incidents, including patient deaths, to ensure any areas of learning were identified.

Staff understood the duty of candour; when things went wrong, staff apologised and gave patients clear information and suitable support.
 

The service had referral and admissions processes that meant essential information about a patient was received to determine if a patient’s needs could be safely met on the ward. Staff worked well with other agencies to gather this.

At the time of inspection there were very high pressures on mental health services to have beds available for inpatient care. The trust had oversight of admissions and discharges via the Acute Referral Centre (ARC). This involved directorate-level daily bed management huddles and communications with wards.

Some staff told us there was pressure to discharge patients to maintain bed availability before patients were clinically ready for discharge. However, the trust and directorates have processes in place to monitor inpatient readmission rates to ensure discharges are clinically appropriate. The information provided by the service showed no significant increase in readmission rates, which was in line with the national average.
Local directorates also monitor re-referrals into community teams, for instance, in Southwark, out of 190 discharges from CMHT/AORT/Rehab to GP, only 43 we re-referred between June 2024 and June 2025 (23%).
There was a process in place around some early admissions where a new patient would arrive on the ward before the discharged patient had left the communal space.

The trust was piloting a QI project ‘Home before lunch’ for adult inpatient wards to improve the discharge process. This was tested in Croydon (Fitzmary 1 and Tyson West 1) and Lambeth (Nelson Ward). The wards had completed the first 12-week cycle.

The trust monitored re-admission rates and these were reported to the trust board. The most recent readmission rates were outlined in the directorate integrated quality and performance report, so that overall progress could be monitored.

Patients were moved between wards only when there were clear clinical reasons or it was in the best interest of the patient. Staff told us they did not move or discharge patients at night or very early in the morning. Patient transfers were planned and took place at times that were appropriate for the patient and team.

Staff involved external organisations such as physical healthcare services and social care services to provide a continuity of care with the service and post-discharge. Community teams were invited to ward rounds and discharge meetings.
 

There were some areas of improvement identified around consistent safeguarding practice and training.

Staff undertook mandatory training in safeguarding adults and safeguarding children at levels 2 and 3. However, some wards had low completion rates. On 4 wards, compliance rates were between 50% and 67%. This was a breach of regulation 18 staffing.

Across most wards we saw that staff managed safeguarding concerns in line with trust policy, including informing the local authority of concerns where appropriate. At Croydon PICU, staff had not managed three patient safeguarding allegations in line with service policy. We raised this to the trust at the time, who took immediate actions to investigate the allegations and involve external organisations where needed.

The service had appropriate policies in place for staff to follow, when a safeguarding concern was identified. This included a policy on “Managing Safeguarding Allegations against people employed in a position of trust (PiPOT)”. In general, the service worked with people to understand what being safe meant to them and the best way to achieve this.

Staff had training in PREVENT to identify patients at risk of being radicalised. They understood how to recognise and report abuse or concerns about radicalisation.

There were systems in place to safeguard children who visited, using a family room which could be booked in advance and was away from the wards.
 

The evidence showed some shortfalls.
Staff assessed and discussed risk regularly, but there were some inconsistencies in the completion and recording of therapeutic engagement and observations and we found some gaps in reviews and records for patients being cared for in seclusion. The service had made improvements to practice around risk assessments, which was a breach of regulation at our last inspection.

We reviewed 44 care records across all wards.

We saw that all records had a risk assessment that staff completed at the time of admission. In most cases, we saw that staff updated these regularly, including after any incidents. This ensures all staff have up to date information about current risks and how to manage them. In two cases we saw risk assessments had not been updated following an incident. The trust had been working to improve consistency and quality of risk assessments.

In all the wards we visited, the multidisciplinary team reviewed the risks presented by patients in daily handover meetings and safety huddles. Risk was also discussed at ward rounds, which patients attended, along with their family or carers, if appropriate. Staff used the Dynamic Appraisal of Situational Aggression (DASA) scoring to consider patients’ changing presentations.

We reviewed therapeutic engagement and observation records and found that staff did not always keep accurate records or carry these out in line with trust requirements. We saw some examples where staff were not recording the detail on the observations form that was required. For example, not recording the time of observation and a lack of detail about patients’ mindsets, often just recording their location. At nighttime observations on Jim Birley Unit and Eileen Skellern 1, staff did not include the position the patient was in, so it was not possible to see if they had moved at all. The trust monitored the completion of therapeutic engagement and observation records through clinical safety audits, but the issues identified on the inspection had not been picked up. In addition, in 6 of 11 wards, 16 of the 20 observation records showed staff carried out observations at predictable intervals, such as 15, 30, 45, and 00 minutes past the hour. This means patients may have a predictable time period in which to attempt to self harm and is not best practice. This was a breach of regulation 12 safe care and treatment.
Since the inspection, enhanced care has now been introduced in the trust and fully rolled out; the system allows for more options for patient positioning and mindset. Also has accurate time stamping. The new electronic platform randomly generates time for intermittent reviews. At the time of the inspection, this had been discussed in the ward business and Governance meetings,1:1 check was carried out with individual staff during shifts.

We found some gaps in reviews and records for patients being cared for in seclusion. The trust integrated quality and performance report which went to the board reported on the number of seclusions. In July 2025 there were 22 incidents of seclusion. Four of 6 seclusion records we reviewed did not have a seclusion care plan documented or implemented during these episodes. For one patient on Eileen Skellern 1, nurse reviews took place every 4 hours instead of every 2 hours. In Croydon PICU, the medical review of the patient did not take place within the hour, which it should have done. This was a breach of regulation 12 Safe care and treatment.

The trust delivered training in the prevention and management of violence and aggression. In 2023 the trust updated their training so that it was certified against the Restraint Reduction Network National Training Standards and implemented Seni’s Law, the Mental Health Units (Use of Force) Act. This Act seeks to prevent the inappropriate use of force, ensure accountability, and promote transparency. The trust aimed to change culture around using restraint, instead focussing on engagement and preventative strategies. Staff were required to attempt all that was reasonably possible, before using any physical intervention. Patients across wards told us they did not always think this was done. The trust collected and analysed data about physical intervention, to drive improvement. The trust integrated quality and performance report which went to the board reported on the number of restraints and prone restraints. For July 2025 there were 198 uses of restraint across the whole trust and for most months in the previous year the number of restraints had been below 200. In July 2025 there had been four uses of prone restraint only one on an acute ward or PICU. Each incident was individually investigated.

The trust had policies and procedures in place to prevent contraband and illicit substances from entering the ward. Prevention strategies included the use of drug-detection dog searches on wards and “Cuppa with a Copper” sessions, which enabled carers to discuss any concerns directly with police regarding access to illicit substances. When risks were identified, staff facilitated random urine screening, delivered patient groups supported by the Dual Diagnosis Lead, and implemented supervised visits, ensuring a proactive approach to managing and reducing substance-related harm. We saw examples of how staff managed this risk in an individualised way with patients. Despite this, 3 of the 16 carers we spoke with told us their relatives had accessed illicit substances using the service.

No concerns were identified in relation to facilities in the other wards. Patients had access to communal areas, including a patient fridge and hot and cold-water dispensers, and were able to select from a range of options on the daily food menus.
Staff aimed to develop and share care plans with patients, and although we saw this was mostly done well, there was a variation in this across wards. Data from monthly patient experiences audits indicated some wards did this well and others had improvements to make in this area. 76.2 % of patients surveyed by the trust said they had received a copy of their care plans. The lowest rate was at 33%, and the highest 100%, on Lucas Ward. The trust should continue to work on embedding consistency in this area.

Informal patients were able to leave the wards, and there was accessible information for them about this.
 

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

We conducted an environmental tour of all 14 wards visited across the trust.

Staff completed and updated the environmental risk assessments of all ward areas, mitigating any risks identified, such as ensuring that rooms with ligature anchor points were used under staff supervision. Staff were aware of environmental risks on each ward and described ways of working that took these into account.

We reviewed seclusion rooms during this inspection. The seclusion rooms were maintained in line with legal requirements. They had 2-way communication with a clear view for observation and patient access to a toilet, shower, and a clock. Staff could also adjust lighting and could play music if the patient wished. At Croydon PICU, the trust were working to address concerns they had identified regarding the closed-circuit television (CCTV) in the seclusion room, specifically in relation to the coverage and quality of the footage. The trust had measures in place to mitigate these risks and staff were aware of these measures.

Patients had their own bedrooms, which they could personalise, and they had access to a range of facilities and equipment to support treatment and care. Most wards had en-suite facilities. However, none of the bedrooms in the Southwark wards did, meaning patients had to share toilets and bathrooms.

Staff used the clinic room to carry out examinations, and patients had access to activity and therapy rooms. This promoted dignity, comfort, and engagement in recovery and supported a therapeutic environment.

The trust had clear policies and practices around sexual safety and management of the environment. Staff were aware of how to report and manage incidents relating to sexually inappropriate behaviour.

The trust adhered to National Quality Board standards and used the Mental Health Optimal Staffing Tool (MHOST) to inform safer staffing. All wards undertook biannual Safer Staffing Reviews, with staffing levels set to national guidelines, and additional staff booked when patient need or acuity exceeded baseline levels. Daily Safe Care Huddles reviewed acuity, identified high risk concerns and allowed redeployment of staff. The trust also introduced a PICU lead and maintained safeguarding processes, daily MDT planning, patient community meetings, and staff wellbeing support. Staffing and safety were monitored through monthly and board level oversight, and patient safety forums. To reduce restrictive practice and manage violence, the trust monitored uptake of Seni Lewis training and the safety interventions, audited via the Least Restrictive Care Audit and reviewed through governance structures.

Despite this, staff spoke of the main challenge to the service being staffing numbers during elevated levels of acuity on the wards. Patients and staff expressed concerns about risks relating to acuity on Tyson West 1, Jim Birley Unit, Eileen Skellern 1, Lucas ward, and Wharton ward. Jim Birley Unit and Wharton ward noted a high level of incidents, including property damage, assaults on staff and other patients. Ten of 76 staff we spoke with across the trust told us they felt wards were unsafe due to high acuity and patients not meeting criteria for PICU. Some patients described concerns for their safety from other patients on the ward, following incidents of assault between patients. On the day of the inspection, although the staffing level was in line with safer staffing standards for the number of patients on Wharton ward, the high acuity on the ward had resulted in multiple incidents, a total of 5 assaults within 24 hours. On this ward, 3 members of staff were currently on leave due to patient assaults. We raised our concerns with the senior managers during the inspection to review staffing levels and provide support for both staff and patients. In response, the trust implemented an immediate action plan, extra staff were booked in, and additional provision was made for senior staff to be present on the ward.

In five of 11 wards, staff and patients told us that staffing numbers impacted their ability to meet the needs of patients. On Jim Birley, staff had to escort patients to the garden as it was two floors below. Patients told us they could not always go to the garden when they wanted as staff were not always available to escort them. On Lucas Ward, several patients reported loss or delay of escorted leave due to staff availability. One patient told us, “they always change the goal posts with getting leave, so I don’t know when I can go.” The trust was aware of this so audited compliance with section 17 leave across wards. The response rate to the audit question ‘If you were given accompanied leave, have you been able to go out?’ across all 14 wards was 92.2% yes. The Trust had implemented several mitigations, including biannual Safer Staffing Reviews informed by the mental health optimal staffing tool data, daily safe care huddles to adjust staffing to patient acuity, and set staffing levels in line with national guidance. On Jim Birley, the garden was accessible, information was displayed for patients, and ward staffing could be flexed to support access. On Lucas Ward, daily multidisciplinary planning meetings allocated staff to ensure patients receive their escorted leave. While these measures demonstrate attempts to mitigate pressures, they had not fully prevented the issues experience by patients.

There was high compliance with some online mandatory training, but there were some gaps in face-to-face training, including Basic and Immediate Life Support, Seni Lewis training (de-escalation and restraint training) and level 2 of Oliver McGowan Training. This was known to the trust and training for staff was booked for next available sessions.

The trust vacancy rates had reduced over the last few years, with sustained reduction between April 2022 (19%) and February 2025 (11-12%). The trust said it continues with its workforce improvement plans to improve this further to ensure standardised care for patients and improve staff experience.

Managers gave each new member of staff a full induction to the service before they started work. New staff had a trust induction before starting work on their ward.

Managers supported staff with appraisals, supervision and opportunities to update and further develop their skills. Supervision for clinical staff was provided monthly.

Jim Birley Unit had support from 4 volunteers to support patients with activities in the evenings and at weekends.
 

Evidence shows a good standard of care
The evidence showed a good standard. The service assessed and managed the risk of infection, detected and controlled the risk of it spreading and shared any concerns with appropriate agencies promptly.

Staff followed infection control principles, including appropriate handwashing techniques, use of personal protective equipment (PPE), including aprons, masks, gloves, and hand sanitiser, which was readily available. Staff maintained equipment well and kept it clean. There were ‘clean’ stickers visible on the equipment.

Most of the ward environments were clean. Regular hand hygiene and infection control audits were taking place. There was evidence of ward audits on cleanliness. There was oversight of cleaning through contract review meetings, the directorate’s monthly environmental meeting, weekly IPC meeting and quarterly IPC committee meetings trust-wide. The trust IPC team completed regular IPC and Environmental audits, which require a ward action plan.

There were some concerns about pest infestations on some of the wards, but these were being treated by an external contractor. The service was aware of this issue, and the IPC team was actively monitoring wards and liaising directly with their pest control contractors.
 

People’s medicines were appropriately stored, prescribed, supplied and administered in line with the relevant legislation, current national guidance or best available evidence, and in line with the Mental Capacity Act 2005. We found one area of improvement, that staff did not always record the reasons ‘as required’ (PRN) medicines were administered.
Our medicines optimisation team visited 12 wards across the trust and reviewed the medicines administration records and care records for 50 people. We reviewed policies and procedures. We reviewed administration records against relevant Mental Health Act consent to treatment documents.

We completed checks of clinic rooms, emergency equipment, and medicine storage. Emergency medicines were kept in the treatment room and were in line with good practice. We saw records of daily checks of all emergency medicines and emergency equipment. Oxygen was available and appropriately stored.

The service 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. Patients and families were educated by pharmacy professionals on the medicines they were prescribed. Treatments with medicines were chosen by a drive for a safe, successful and sustainable discharge back into the community that met the patient’s needs and preferences. Pharmacists provided education on medicines, including side effects, and helped patients build confidence in managing their own care. This included the use of medicine reminder charts and translation services where needed.

The service had systems and processes in place to safely administer and record the use of medicine. The staff followed clear systems for prescribing, storing and administering medicines. Controlled drugs and high-risk medicines were checked regularly and stored securely. Pharmacy teams were well integrated and supported staff with medicines reconciliation, audits and training.

The service made good use of long-acting injections to support stability and reduce the risk of relapse. These were used to help patients transition safely back into the community. Where appropriate, patients were also offered genetic testing to support the early and safe use of clozapine (an antipsychotic medicine). This helped identify those who may benefit from adjusted monitoring, particularly for patients with benign ethnic neutropenia.

Patients prescribed medicines that required additional physical health monitoring, such as clozapine, lithium, or high-dose antipsychotics, were monitored in line with national guidance had we saw regular checks in place. Staff were aware of the impact of high-risk medicines on physical health. Risk management plans were in place.

The use of rapid tranquilisation (a medicine administered via the parenteral route for urgent sedation) was monitored. The trust integrated quality and performance report which went to the board reported on the number of times rapid tranquilisation was used. In July 2025 this was used 59 times across the whole trust. We saw that post-dose physical health monitoring following rapid tranquilisation (RT) was usually completed in line with trust policy. We found one example on Jim Birley Unit where post-RT monitoring protocol was not followed. The trust had been working to embed this practice consistently and in audits of 40 cases they had carried out, staff had completed monitoring in line with guidance, including recording if a patient declined at any point. Audits indicated that staff offered patients debriefs after RT had been used.

There were some gaps in patient records when recording PRN (‘when required’) medicines use. In several cases, the reason for administration or the outcome was not documented. We saw PRN medicines were sometimes given for reasons not indicated by the prescriber. We raised this with the staff during the inspection. This was a breach of regulation 12.

The Trust monitored medicines management compliance by carrying out medication competency, medication auditing and weekly clinic room checks. However, on Jim Birley Unit we found that some opened liquids in the clinic room had not been labelled with the date of opening.