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
• Environmental sustainability – sustainable development

We have not awarded this service a score for Well-led.

Find out about when we will not publish a key question score and what we look at when we assess Well-led.

The trust had a strategy in place which ran to 2026, and work had started to refresh the trust wide strategy with appropriate consultation. The trust was in the process of preparing a medium-term financial strategy but without costed plans for clinical services in place to inform its content. No consultation had yet taken place on planning assumptions and consequential service impacts.

Throughout the well led review we received mixed feedback about the visibility of senior leaders. Feedback from many of the staff we spoke with about the culture of the organisation was concerning. The presentation from the trust at the start of the well led inspection had mentioned anti-racism as a challenge but not the wider culture which reflected a disconnect between the senior leaders and front-line staff.

Trust leaders had ensured there were shared values and a strategy in place. The trust was in the final year of its 5-year strategy: Aiming High; Changing Lives which set out 5 strategic ambitions that they were continuing to work towards until 2026. The strategy had been co-produced with people who used services, staff and stakeholders. Co-production had taken place through place-based events, staff events and surveys. Staff, people who used services, governors and external stakeholders had participated in the work.

The strategy had 5 key ambitions with the aim of ensuring all services operated at the very best and safest level for children, young people, adults and older adults. The trust aimed to use a data-led and individualised approach to drive continuous improvements in the way they care for people. The 5 strategic ambitions were to deliver outstanding mental health care, be a partner in prevention, being a catalyst for change, building a culture of trust together and becoming effective and sustainable.

The trust had a commitment to share progress against the strategic ambitions and metrics through 6 monthly public strategy progress events. The events aimed to seek and build trust with local communities around the trust's strategy. Whilst these had taken place in 2024 the event for June 2025 was repurposed to support the trusts planned strategy relaunch in autumn 2025.

Senior leaders referred to the trust values and strategy. The governance arrangements ensured that the priorities of the trust were monitored. For example, there were twice yearly strategic priority updates presented at public board and strategic targets were also monitored via the Integrated Quality and Performance Reports (IQPR). The report from July 2025 presented the strategic measures linked to the trusts ambitions to enable the measurement of progress against the delivery of the strategy. These showed that as of March 2025, the trust had made some progress in reducing restrictive practice and had seen a sustained reduction (35%) in prone restraint use in 2024/25 compared to 2023/24. There had been an overall improvement in waiting times for working aged adults to 87% of people being seen within 28 days. The trust had the highest number of people participating in research across all mental health trusts in England with 6,395 participating. However, the trust was still below the trust target of 95% with only 85% of friends and family giving a positive response. The staff engagement score in the staff survey also showed a decline since the launch of the strategy from 7.06 in 2021 to 6.92 in 2024. For equality diversity and inclusion, the NHS Staff Survey score in 2024 was lower than the 2021 score and remained below the average for all mental health trusts.

At the time of the inspection the trust was going through a refresh of their strategy and work for this was at an early stage. The plan was for the strategy relaunch to take place in summer 2026. The refresh was being supported by a multidisciplinary working group which included staff, service users, carers and community members. Pre-engagement started in September 2025 with plans to launch a public consultation mid-November 2025. Several types of engagement including public events, surveys, focus groups for particular communities informed by an equalities analysis, briefings for service user and carer groups and briefings for community and voluntary sector organisations were planned.

We heard that there were plans to develop a clinical strategy, but this work had not yet taken place. The Chief Medical Officer will lead this work and said it would largely focus on the development of community-based services to meet the needs of local populations.

The trust told us that it was preparing its medium-term financial strategy. This was taking place without costed plans for clinical services to align with. Outline guidance from NHSE had been shared through the trust finance performance and investment committee. However, we were told that no consultation had yet taken place on planning assumptions and consequential service impacts. As part of its current financial turnround plans the trust had taken steps to tailor its services to reflect better alignment with commissioned contract values. The trust remained concerned that commissioners were not providing sufficient funds to meet its assessment of demand and need.

The trust had a dedicated estates team however had been without an up-to-date estates' strategy. The new 5-year Estates and Facilities Management Strategy was currently being drafted. The draft was being shared with wider stakeholders and service users for feedback and plans were for this to become a live document from 2026. However, the trust estates team was undertaking modernisation work to manage access to support from the estates team and understand blockers. Two major developments were nearing completion at the Maudsley Hospital site. Construction of the Pears Maudsley Centre for Children and Young People (PMCYP) at the Maudsley Hospital site was still underway following significant delays to the build completion and handover by the main contractor. New Douglas Bennett House (NDBH) which was replacing Lambeth Hospital had been handed over to the Trust for final ‘fit out’ works, training and orientation. This building was also delayed due to build completion issues from the contractor which included the installation of a replacement hot water system. Both buildings were originally planned to be open in 2023, but the delays meant they would not be operational until 2026.

The trust had a 5-year Autism Strategy which was launched in 2024. This recognised the need for a specific focus on autism within the trust and the vision to become an autism confident organisation. The strategy identified 6 key recommendations to focus on including training and awareness, service user and carer experience, access to services, diagnostic pathways, treatment pathways and autism in the workforce. Stakeholders fed back that they had been involved in the development of the strategy.

The trust had a Medicines Optimisation Strategy and objectives for 2025/26, and staff reported engagement in its development and implementation.

Throughout the well led review we received mixed feedback about the visibility of senior leaders and the culture of the organisation. The board held all its meetings at Maudsley Hospital rather than rotating them round different sites which limited how accessible it was to attend. Board meetings included a session hearing from people who use services and carers at the start of every other public board meeting. The trust supported accessibility by allowing attendance remotely where appropriate. Board papers were available in advance and following meetings these could be accessed online.

There was a programme of visits arranged for the chair and governors to services which other non-executive directors could join. These were described as rather ‘stage managed’ by people we spoke with, and it was acknowledged that this arrangement would benefit from being reviewed. The new chair had arranged to visit a wide range of services since joining the trust and some non-executive directors had also arranged visits to services to support their knowledge and understanding of the work of the trust. There was also a programme of executive director visits to services.

Staff knowledge of the senior leadership team was mixed with some staff not knowing who the executive team were, however, the trust covered a large geographical area with large numbers of services to visit. Feedback about the visibility of the Chief Nurse was positive who staff identified as an exemplary leader. Medical staff also valued the recently appointed Chief Medical officer. The trust had a weekly broadcast often led by the Chief Executive to increase visibility. Since joining the trust in June 2025, the new Chair had set up monthly blogs and articles outlining her role and priorities. This included topics explaining what happens at a board meeting and emphasising how people can participate in board meetings.

Staff told us that they mostly found their direct teams and local leadership largely accessible and open in their approach. However, feedback about managers above team leaders was more negative. Whilst staff said they knew how to raise concerns, they said that they often did not feel their concerns were taken seriously. A number of staff told us they did not feel safe to raise concerns and expressed frustration with the lack of action taken by the trust to address things. Whilst staff said senior leaders were aware of the challenges the organisation faced they expressed concerns that often the necessary action to drive improvements did not happen in practice.

Trust leaders told us that the development of a better culture that promoted equality, diversity and human rights was a strategic priority. However, this did not mirror what some staff were experiencing on a day-to-day basis. Many staff described a disconnect between front line staff and senior leaders and they did not feel their experiences were heard or that their work is always appreciated. Many staff told us that they no longer felt that they wanted to provide feedback through the staff survey or other means as they did not believe this would make a difference. This was reflected in the low completion rate for the staff survey. The staff survey results indicated that whilst staff working across the trust were finding their day-to-day work experiences challenging the overall 2024 national staff survey was mostly negative relative to other mental health, learning disability and community trusts. The response rate had been 39% compared to a national average of 54% and worse than the previous year. The trust scored worse than the national average on all indicators except ‘we are always learning’. The trust had an engagement rating of 6.92 compared to a national average of 7.07 and 7.29 for being compassionate and inclusive compared to a national average of 7.55.

Since the last inspection the trust had taken steps to try and improve the culture. In February 2022, the trust relaunched their ‘Creating Our Culture’ programme. The trust held conversations, workshops and surveys with over 1200 members of staff and created the new ‘Values and Behaviours Framework’. The trusts values were kindness, respect and together. Staff were aware of the trust values and understood how they applied to their roles. The trust aimed to embed the framework throughout the trust including key policies that would support a positive change to the culture of the organisation. The trust told us they had processes to identify and address behaviours that were inconsistent with the values of the NHS. Some staff did recognise the trusts commitment to improving the culture of the organisation. However, many staff told us that they felt their concerns were not always taken seriously or addressed.

Many staff told us that employee relations and human resources within the organisation was poor. Staff also raised concerns to us about the grievance process and how individual cases were addressed. Staff told us that cases investigating poor staff attitudes including bullying and harassment were often not investigated appropriately, did not follow trust policy and protocols and took too long to conclude.

Some staff expressed concerns around recruitment into senior posts and that policies and protocols were not always adhered too, so this was a fair and equitable process. Staff said that recruitment to some vacancies for the safe running of services was still not happening in a timely manner. This was having a significant impact on staff morale.

Staff expressed frustration at being excluded from strategic discussions and organisational initiatives. Staff described the culture within the trust as demoralising. Some staff told us the trust prioritised financial metrics over quality. Directorate leaders recognised employee relations was on an improvement journey and still had work to do. They said having a link person for each directorate was positively impacting the work between operations and employee relations. The trust had taken some actions to improve recruitment processes including changes to policy and the diversity in recruitment process. However, the benefits were not currently translating into a positive experience for many frontline staff. Some of the trust governors reported that they were actively involved and engaged with the trust. They reported to have recently been involved in the recruitment of the new Chair and were actively discussing recruitment of the non-executive directors.

Feedback from system partners commented on how the current leadership was strong and engaged in system work as a whole. They found that the trust was open and willing to share information with system partners. They were also able to recognise where services needed to improve.

The trust acknowledged the need to develop the board, including recruiting non-executive directors, refining the induction of non-executive directors, strengthening the board development plan. This work was underway. Clinical leadership at a trust and directorate level was not working effectively with unclear roles and accountabilities for members of the multi-professional leadership teams. This was limiting the ability of professional staff to effectively challenge decisions.

We observed the trust’s board meeting, attended several governance meetings and reviewed minutes. These included the subcommittees of the board. In all meetings we saw leaders acting with integrity, respect and demonstrating a passion for delivering services to meet the needs of the communities.

The trust’s board comprised of 9 executive directors including the Chief Executive and 8 non-executive directors including the trust’s Chair. Since the last inspection there had been several changs to the board. This included the trust appointing a new Chair, Chief Medical Officer (CMO), Chief Operating Officer (COO), Chief People Officer (CPO), Chief Commercial Officer and Director of Strategy and Transformation. There had also been the appointment of a number of non-executive directors. The non-executive directors brought a range of experience including experience in the acute sector, social work, social housing, research, advocacy, human rights, cyber security and finance.

The Chair and Chief Executive were both mindful of the succession planning for board members. At the time of the inspection a recruitment process was underway for new non-executive directors that included replacing people who were near the end of their term of office. This had been discussed at the September council of governors meeting where it was clear the trust and governors wanted to recruit experienced non-executive directors including a person with a clinical background. Since the well led assessment the trust had made a number of changes to strengthen governance including recruiting a new audit committee chair, director of corporate affairs and an executive lead for commercial and partnership work. The trust had also brought in a part time advisor to support governance. The Chief Executive Officer had left the trust and the Chief Operating Officer was now the interim Chief Executive Officer.

All the executive directors managed senior leaders who were developing the skills and experience to potentially be future trust leaders. They also considered the diversity of the board and recognised the importance of recruiting more members from global majority backgrounds.

The executive directors had portfolios covering all the necessary areas of work for the trust. This included patient safety, quality of care, risk management, performance, finance and organisational development. Some of the executive directors had very large portfolio’s and we were not assured they had the necessary support to enable them to have the capacity for these roles. For example, the Chief Operating Officer was accountable for the financial turnround, estates and facilities functions and led the quality improvement function. Having these functions being held by one portfolio holder inherently reduced the level of professional challenge and the benefits of different functions being shared across the executive team and their different backgrounds and experiences. In addition, the trust had recently lost the Director of Therapists post. The Chief Nurse was now responsible for social workers and Allied Health Professionals (AHPs) and the CMO for psychologists and psychotherapists, which added significantly to their portfolios.

The trust had significant instability in its’ medical leadership prior to the CMO joining the trust towards the end of 2024. Staff said the new CMO was making positive changes with a strong focus on improving engagement with medical staff. However, we had concerns around the capacity of the CMO to dedicate the required time to this with the addition of psychologists and psychotherapists to their portfolio.

Members of the board were positive about the arrival of the new Chair, but some also raised issues which highlighted that there was scope for the board to operate better at a strategic level. This inspection identified concerns relating to finance, governance and culture across the organisation which meant there was scope for improvements in how the board and its sub-committees conducted their business.

There was a board development plan in place with 8 sessions planned for 2025. The content of the sessions included topics such as board effectiveness, the strategy refresh, urgent and emergency care, integrated neighbourhoods, risk appetite and horizon scanning. However, some non-executives raised concerns that often board development focused on issues where there had not been sufficient time for discussion at the board or sub-committees and were not strategic. The new Chair recognised the need to focus on board development, and an independent consultant had been recruited to support this work. This included ensuring effective inductions and development for new non-executive directors including development for those who had no experience of mental health services.

The trust had a fit and proper person policy, and board members had completed checks in line with the requirements, including a thorough search of their social media.

The trust was organised into 6 directorates. Four of these were aligned to geographical areas with a focus on the services delivered at place (Croydon, Lambeth, Lewisham and Southwark). Lewisham included Addictions and Croydon included Behaviour and Development Psychiatry. The other two directorates were CAMHS and Psychological Medicine, Older Adults and Neurodevelopmental services. Clinical leadership (medical, nursing and management) was available in each directorate. Over the last 2 years there had been a number of changes to some of the medical and operational leadership roles within the organisation. Feedback from system partners was that these changes were positive and resulted in stronger operational oversight and increased openness with the system. However, many staff described working in an organisation which was top down and centrally controlled especially in relation to the implementation of financial controls. The multi-professional leadership at the directorate level was not always working well with some leaders, especially associate medical directors feeling they could not contribute appropriately to decisions.

The recently appointed Chief Medical Officer recognised the need to strengthen medical leadership across the organisation including at a directorate level with clarity of role and accountability. This needed to happen for the leadership at a directorate level to ensure the different professional skills were able to contribute effectively.

There was evidence of individual executive directors being involved in partnership working. For example, the Chief Executive sat on the Integrated Care System (ICS) as a partner member representing mental health to ensure there was shared vision and strategy for mental health services across the sector in south east London. The ICS board shared a joint Executive Director for Communications and Engagement with the trust. The Chief Executive chaired the system wide Digital Strategy Board and both the Chief Executive and Chief Financial Officer sat on the ICS Sustainability Board looking at the short and medium term financial recovery position and how efficiencies could be made by partners working together.

The trust does not have a culture where staff feel safe to speak up and know that their concerns will be addressed. The current Freedom to Speak Up Guardian had limited time to carry out the role. Freedom to speak up was an underdeveloped area for the trust and trust recognised that the speak up arrangements needed to be revisited.

The trust had identified an executive lead and a non-executive director lead for Freedom to Speak Up (FTSU). In addition, there were currently 35 FTSU champions and 11 ambassadors who had been identified across the trust to promote awareness. Of these 46 people, 19 were Black, 22 were White and 5 were Other/Mixed ethnicities. There were 37 women and 9 men. However, the Freedom to Speak Up Guardian (FTSUG) was not a full-time post and we were told the Guardian only had around 10% protected time for the role. This was concerning given the size of the organisation, long standing cultural issues and staff survey results. During our interview with the FTSUG and Chief People Officer (CPO) there was recognition the structure of FTSU needed to be revisited. They were proposing to board that a FTSUG should be recruited with the required protected time to do the role. However, this was not in place at the time of our assessment.

The trust had a FTSU strategy and policy. This had been developed following a board self-assessment of the arrangements for speaking up. The FTSU strategy had been developed following an extensive engagement exercise. The strategy built on the learning from the engagement work and reflected the national Guardian's Office template. The focus of the new ‘Raising Concerns Strategy’ was for the trust to create a culture that encouraged staff to speak up with the support of management and leadership teams. The strategy listed 6 specific actions which were being actioned by the FTSU ambassadors and the CPO. The FTSU ambassadors were leading 2 of the 6 actions which included communication and visibility plans for promoting FTSU. Various activities were arranged throughout the year to support and promote the new strategy. This included live broadcasts, FTSU events, presentations and drop-in sessions for staff. There had also been various directorate-based activities such as posters being placed around services, night visits to wards and newsletters.

The CPO was responsible for the remaining 4 specific actions. This included improving the trusts scores across the 4 NHS Staff Survey relevant questions, identifying learning and improvements, experiences being shared with the board to drive improvements across the trust and leading on mandatory training for managers.

The trust encouraged all staff to complete ‘Speaking up’ training, however, this was not mandatory. Managers were required to complete ‘Listening up’ as part of their mandatory training. Board members and the executive leadership team were required to complete ‘Follow up’ mandatory training. The FTSU ambassadors and champions were encouraging staff to complete the training.

During our inspection of community and inpatient services we found there was good awareness of the FTSUG and their role. However, we received mixed feedback from staff about whether they felt safe speaking up within the organisation. Many staff we spoke said they did not feel safe raising concerns. Some staff said they would feel safe raising concerns but said concerns would not be taken seriously. Some staff told us they had raised concerns about poor behaviours, bullying, harassment and no action was taken by managers. Staff also said where grievances were raised, they were handled poorly by employee relations. Cases were often on hold for long periods of time, poor support was in place and actions were not taken to address behaviours that went against trust values. However, some staff reported that they felt safe raising patient safety concerns with local managers, such as ward managers and felt confident they would be acted on. There was less confidence about whether concerns were acted on when they were escalated further to senior management. More time and ongoing work was needed to fully rebuild trust with staff and ensure they feel able to confidently raise concerns.

The 2024 NHS Staff Survey showed that staff agreeing with the statement ‘I feel safe to speak up about anything that concerns me in this organisation’ had fallen slightly from 61.6% in 2023, to 57.6% in 2024. This was below the national average of 66.6%. The survey also showed that in 2024, 44.7% agreed with the statement ‘If I spoke up about something that concerned me, I am confident my organisation would address my concern’. This was a decrease from 49.4% in 2023. The trust score was below national average in 2024 of 54.9%.

The FTSUG reported to the quality committee and submitted regular reports to the committee and board. The July 2025 report to committee stated in 2024/25 there had been 99 FTSU contacts made. The demographic of the staff raising concerns was reported to the quality committee. Of the 99 contacts, 22 (22%) were male, 73 (74%) were female and 4 (4%) were unknown. There were 44 (44%) staff from global majority backgrounds, 51 (52%) were White and 4 (4%) were unknown. The 5 top issues consistently emerging from the contacts were: Bullying, toxic leadership and culture of fear; Discrimination, inequality and lack of inclusion; Poor grievance handling and inadequate HR support; Suppression of concerns and retaliation; and unsafe working, poor change management and job insecurity. The trust were not using FTSU contacts to identify hot spots within the organisation. The FTSUG stated this was to protect the anonymity of the staff. Following the assessment the trust informed us that the information provided in the FTSUG annual report was incorrect as artificial intelligence had incorrectly identified themes. As a result a senior FTSU ambassador had reviewed the cases and identified the following themes: Problem with leadership, culture and poor management; Discrimination and inequality; Fear of speaking up/retaliation; HR and grievance failures; Workload and patient safety; and financial pressures impacting care.

The trust had identified broader organisation themes which required a specific focus. This included feedback from the BME staff network around the trust's response to the far-right extremist riots and racist attacks in 2024. During a ‘Time to Talk’ session over 205 staff attended and raised concerns around the lack of/or inconsistent guidance and support that was available for staff during this time. The trust identified learning from this including the importance of effective communication and the impact on staff well-being. However, feedback from staff was that learning had not been shared and there was poor communication around any changes that would be made in the future. Following the well led assessment the trust told us they acknowledged their response during the civil unrest did not address the needs of the staff. As a result, clear guidance has been issued to managers and staff identifying ways to support staff to feel safe during periods of civil unrest.

The trust completed a thematic review following a cluster of Patient Safety Incident Investigations Developing a positive culture and FTSU were identified as themes from the review that required action. The trust recognised this work was ongoing and had developed a joint improvement plan with the south east London ICB.

Since the last inspection the trust had developed an anti-racist strategy and action plan. The trusts anti-racist policy was still under development despite the anti-racism plan being launched in 2023. However, feedback from staff and work force race and work force disability equality standards, showed that whilst there had been progress in some areas there was more work to do. The trust had well established staff networks. Networks also had a clearly identified executive director sponsor. However, we received mixed feedback regarding how involved the executive directors were in engagement activities with the networks. Some networks felt sidelined by the focus on racism.

The trust had launched a new secondment, temporary promotion and acting up policy. They had also introduced a new starting salary policy. This policy had been introduced to ensure a consistent approach was adopted when establishing the starting salaries of new employees and existing staff moving within the organisation, including promotion, acting up and secondments. The trust recruited diversity in recruitment champions (DIRs) which they have embedded into the recruitment process to support all vacancies at band 8a and above. Despite this, we still had staff raising concerns around unfair recruitment and preferential treatment.

The trust had developed new equality objectives to replace the Integrated Equalities Action Plan (IEAP) which ended in 2023. The 2023 to 2026 equality objectives aligned with the core goals of the organisation to support delivery of equity within the trust’s strategic ambitions. The workforce objectives centred around improving the culture within the organisation by improving representation of global majority (diverse group of people who are not considered white) staff in senior roles, reducing overrepresentation of global minority staff in disciplinary proceedings and improving career progression of disabled staff. The progress report on the actions and outcomes delivered were reported to quality committee and people, culture and communities committee, and once a year to the board. The report presented to board in July 2025 highlighted some progress had been made, however, access to data and data integrity remained an issue.

The trusts performance in in the NHS Staff Survey 2024 was below the national average in all areas except ‘we are always learning’. The trust presented the most recent staff survey results to the board in May 2025 and subsequent action plan presented to board in July 2025. The trusts response rate had decreased from 50% in 2023 to 39% in 2024 which was also below the national average of 54%. Following the assessment the trust provided the trusts response rate for the 2025 NHS staff survey which had improved to 51%. Whilst this was not published yet the trust told us initial results showed improved scores.

The trusts Workforce Race Equality Standard data (WRES) showed some progress had been made. For example, the number of global majority staff believing that the organisation provided equal opportunities for career progression or promotion increased from 37% in 2019 to 47.9% in 2024. There was increased representation of global majority staff in senior roles of band 8a and above (34.6%) compared to 2023 (30.3%). The trusts diversity in recruitment (DIR) process was identified as pivotal in these changes. The trust now had 230 DIR trained staff and planned to increase this to 250. However, there was recognition there was still work to do as representation of global majority staff did not reflect the workforce profile of 52% and global majority staff still remained overrepresented at the lower bands and underrepresented at band 8b and above. Also, the proportion of staff acting up was higher for white staff and proportionally lower for global majority staff. The percentage for white staff acting up was 56.52% which had increased from 52.7% the year before. Overall, there were 16 white staff acting up in band 8a and above roles and only 4 staff from global majority backgrounds. Following the assessment the trust informed us an action plan was in place to address WRES indicators.

The relative likelihood of white applicants being appointed form shortlisting compared to global majority staff in 2024 was 1.4 compared to 1.5 in 2023, a very slight improvement. The trust aimed to reduce representation of global majority staff in formal disciplinary proceedings. In 2019, the likelihood of global majority staff entering formal disciplinary proceedings was 5.84:1. The most recent report to board reported this had reduced to 1.75:1

The 2024 staff survey reports on 4 WRES indicators. White staff reported noticeably better experiences than staff from global majority groups whose experience was considerably poorer. For two metrics there had been increases since the previous year. More global majority staff reported experiencing bullying, harassment or abuse from patients in 2024 (35.6%) compared to 2023 (33.5%) and compared to white staff (23.4%). The percentage of global majority staff experiencing bullying, harassment and abuse form other staff in the last 12 months was higher (23.3%) compared to white staff (20.3%). This had decreased slightly from 2023 but was higher than the trusts performance in 2022.

The percentage of global majority staff experiencing discrimination from managers was higher (14.4%) compared to white staff (9.1%). Performance overtime was remaining relatively stable suggesting despite having the anti-racism action plan in place the trust was not making the necessary progress to improve the experience of global majority staff within the trust. This was also reflected by some of the staff feedback we received where allegations of racism, bullying and harassment were raised. Many staff had concerns that despite the objective to be an anti-racist organisations senior leaders did not take the required action to embed change in the culture of the organisation. We also received feedback which said that Black managers showed preferential treatment to other Black staff with the same heritage. This highlighted the complexity of the anti-racism work which needed to be carried out by the trust.

Representation at board level had decreased since we last inspected in 2021. The executives had 9 members and of these 2 were from a global majority background (22%) compared to 2021 (33%). For non-executives there were 8 members and 3 were from global majority background (37.5%) which had increased since 2021 (25%).

The trusts disability declaration rate had been on an upward trajectory and had increased to 7.71% in 2024 which was almost double the NHS average of 4.9%. This meant staff were more forthcoming with reporting their disabilities to the trust. The trust had implemented an employee self-service system which permitted staff to update their own diversity declaration. Staff were encouraged to use the self-service through various engagement sessions such as ‘Time to Talk’ and monthly network meetings. However, whilst the proportion of staff recorded disability internally had increased it was still significantly lower than that reported through the Staff Survey at 26% of respondents in 2023. The trust had embedded an ‘Ability Passport’ and introduced disability leave guidance which was incorporated into the ‘Disability in the Workplace’ policy. Disability leave was now a type of reasonable adjustment under the Equality Act 2010 and was given as an example of good practice in the Equality and Human Rights Commission Employment Statutory Code of Practice. This Guidance provided an explanation of the differences between disability leave and disability-related sickness absence and shared good practice around providing support to staff.

Staff with long-term conditions or illnesses at the trust reported worse experiences in all of the 2024 NHS Staff Survey, compared to those without at the trust. They also reported worse experiences than the national average in all metrics. Metrics used to evaluate work force disability equality showed polarised findings. Seven metrics showed improvement. Five showed decline and 1 showed no significant improvement.

The metrics showing improvement included the representation of staff identifying as disabled in medical, senior manager and executive level posts when compared to the percentage of staff identifying as disabled in the overall workforce which had slightly improved from 7.3% in 2023 to 7.7% in 2024. The percentage of staff who identified as disabled experiencing harassment, bullying or abuse from patients/service users, their relatives or the public and from managers in the last 12 months had slight improvements. However, the number of disabled staff reporting bullying from colleagues had increased from 51.8% in 2023 to 54.5% in 2024.

The percentage of disabled staff saying the trust had made reasonable adjustment(s) to enable them to carry out their work has seen positive improvements from 72.7% in 2023 to 77.6% in 2024 an increase of (+4.91%). However, this was still below the national average of 79.6%.

The percentage of staff who believed the trust provided equal opportunities for career progression or promotion and the percentage of staff feeling pressure from their manager to come to work, despite not feeling well enough to perform their duties also had slight improvements. Although, this was still worse than the national average. Disabled staff were also still more likely to enter formal capability process than non-disabled colleagues (1.46 times more likely). Following the well led assessment the trust informed us they had developed an action plan to address some of the negative indicators in WDES.

Following the 2024 NHS Staff Survey results the trust acknowledged there was significant work to do to improve the experiences of staff from global majority backgrounds and staff who identified as disabled. A staff survey action plan was presented to board in May 2025 and July 2025. This outlined action the trust would take to improve the trusts response rate and focus on creating a great place to work by improving the culture. The trust planned to launch a ‘living our values’ campaign and set up a ‘back to basics’ taskforce to ensure they were getting the basics right for staff. At the time of our assessment the next staff survey had been launched and the trust were taking action to increase staff engagement. For example, team managers had been set the objective to reach a minimum 50% response rate for their teams and there were weekly communications being sent to staff.

The trust monitored gender pay gaps and the board received an annual report. The median gender pay gap in 2024 showed women earning 5.63% less than men. This was higher than the median gender pay gap for the NHS as a whole, which was recorded as 8.83%. The mean pay gap had decreased by 2.32% since the previous year. Examination of the pay gap within the different pay scales showed that there was little difference in the average hourly rates until Band 8b. The trust had developed an action plan to better understand the reasons for this gap and to put in place measures to address issues identified.

Staff networks had been built to promote equality, diversity and inclusion. Each network reported to the people and culture committee regularly and to the board. The trust had 5 staff networks. Networks had executive sponsors and dedicated budgets and chairs had protected time to deliver their roles. Feedback from members was that executive sponsors engagement varied network to network and needed to improve. They also said protected time and budget was challenging at times. Many staff said that actions taken to address racism had not led to positive changes in teams across the trust. Some networks felt sidelined by a focus on racism.

The networks were:

• Diverse Ability Network

• Lived Experience Network

• Global majority staff network

• LGBTQ+ staff network

• Women's staff network

Networks delivered significant positive benefit to staff. Networks were visible in highlighting concerns, providing support to staff and training to the organisation. In September 2025 the trust were trialling a new format for the people, culture and communities committee. The trust added an additional staff network meeting in advance of the committee meeting to provide additional time for discussion around issues and joint working with the networks. During the first meeting it was identified that executive sponsors should be invited to attend these meetings moving forward.

Following the assessment the trust held an event to appreciate their staff with a disability. The event was joined by various executive team members including the Chief Executive, Chief People Officer and Executive Champion for the Diverse Ability Network.

Whilst the trust had governance structures, systems and processes in place these were not always operating effectively. Our inspection found that some serious matters were not always escalated through the board sub-committees in a timely manner; in some cases the governance arrangements required strengthening to ensure risks were being adequately addressed to safeguard people using services in particular where partnership arrangements were in place; also the governance processes required reviewing to ensure the board could gain assurance that trust wide issues such as the need to replace the electronic patient record system were appropriately identified as a risk with clear plans and realistic timescales for this to be addressed. For inpatient services there was a need to complete accurate records of interventions such as restraint, seclusion and therapeutic observations to ensure that these were undertaken appropriately and safely.

The trust unitary board met 6 times a year. In between there were board development sessions. The topics discussed in the confidential part of the board meeting were appropriate. The agenda was clear but there were too many items, which meant that the meeting felt rushed with not enough time for reports to be adequately discussed.

There were 7 subcommittees of the board. These were quality committee; people; culture and communities committee; finance, performance and investment committee; audit and risk committee; partnership committee; mental health legislation committee; and renumeration committee. The sub-committees fitted in with the board meetings. The finance, performance and investment committee was established at the end of 2024 merging the work of two predecessor committees, the business development, investment and commercial committee and the finance and performance committee. A partnerships in common committee reported to its constituent boards including the trust board.

The non-executive directors were aligned to the subcommittees and also attended meetings which they did not chair to get a broader understanding of the work of the trust. There was a description of the work of each subcommittee. Key risks and updates were shared in a report from each subcommittee to the board. However, this summarised what was discussed during the committees and did not set out details of what the board should be alerted to, assured on were being advised on.

Governance needed to be strengthened particularly at board level and the subcommittees. Executive directors were not always using the governance processes effectively to ensure the right information was available at the right time for consideration by the subcommittees and board. For example, the trust’s executive leadership team had commissioned a “Learning through Experience Review” on the governance and decision-making processes surrounding the 2 large capital projects which reported in April 2025. The review identified areas for improvement to support more effective governance, management and oversight of future major projects within the trust. The report identified weaknesses including inadequate financial planning, fragmented governance and inconsistent clinical involvement.

At the time of the assessment the report had been shared with board members but had not been formally adopted and no action plans agreed. The report was then put on the agenda of the private board in September 2025 but there was insufficient time to cover the topic and so this was deferred to a later meeting. This meant that a significant area of work for the trust with associated strategic financial and quality risks had not been considered in a timely manner. We were told that the audit and risk committee would be charged with oversight of delivering the action plan.

We also found examples of the board being asked to make decisions without being provided with the appropriate information to inform the decision. For example, when we reviewed the papers which had gone to the board about the arrangements to manage winter pressures. They did not include the planning document with the details to inform the decision or confirmation that the planning documents had been considered by a sub-committee of the board.

Governance processes for services delivered through partnership arrangements such as the Lambeth Alliance were not always robust. The CQC assessment of working age community mental health services and crisis and health-based place of safety highlighted several areas where patients were potentially failing to receive a service in a timely manner which could impact on their safety. This included service users held on a waiting list at the Lambeth single point of access. The concerns about the Lambeth single point of access had been escalated. However, whilst some actions had been tried, these had not fully addressed the access issues and an unacceptable risk was being tolerated leaving service users at risk of harm.

The governance processes for the executive directors operated through executive forums including the weekly safety huddle, executive leadership team (ELT) weekly meeting, ELT finance turnaround board, ELT strategic estates board and ELT strategy and transformation huddle. These reported into subcommittees of the board.

There were 6 operational directorates and each directorate was led by a service director with a multi-professional leadership team. Each directorate was held to account at a monthly Integrated Quality and Performance meeting (IQP) chaired by either the Chief Operations Officer, Chief Nurse, Chief Finance Officer, Chief People Officer or Chief Medical Officer. These meetings reviewed the directorates performance, quality of care and finances. These meetings fed into the operational management board. Some found these meetings were working well and others felt they were too focussed on data with little scope for discussion, the development of innovation and support where needed. A few people told us that colleagues had been reduced to tears after attending these meetings, suggesting that the culture of the approach might benefit from some reflection.

The trust had arrangements in place to identify and escalate risks. The executive risk register (ERR) was the top tier of the trust risk register structure and held all strategically significant risks as well as those escalated from directorates risk registers. The ERR was reviewed monthly by the executive leadership team including an assessment of all directorate level risks reaching the escalation criteria that month. Each directorate put current risks on the operational risk register. The risks were scored and the actions to address them were recorded. We were told progress with addressing the risks were monitored through the governance processes. Risks which posed a significant risk to delivery of the trust’s strategic priorities, or risks that could not be mitigated at directorate level were escalated. The operational risk register informed the BAF maintaining oversight of significant risks which, if they materialised, may affect the strategic direction of the trust. The concerns identified during the inspections of the trusts community and crisis services suggested that whilst there was recognition of risks there was a lack of action to drive forward improvements.

The current Board Assurance Framework (BAF) was presented to board in May 2025 as part of the board BAF scrutiny arrangements of the key organisational strategic risks. Board subcommittees were required to undertake scheduled 6-monthly BAF risk deep dive reviews and any changes as a result were escalated to board. As part of the BAF governance arrangements, each BAF risk was assigned to a responsible executive director and a board subcommittee for oversight of each risk. The responsible executive director maintained oversight of the relevant action plans to mitigate their allocated risks and address gaps in controls and assurances. The executive leadership team reviewed all BAF risks monthly (as part of the Executive Risk Register monthly review) and the Director of Corporate Affairs had overall responsibility for the BAF. The trust had recently added estates strategic capital programme and disposals as a key risk which was approved during July 2025 board. The September 2025 BAF aligned to strategic priorities and recorded 10 principal risks. Of the 10 key risks all of them showed no change on the risk score at most recent review, and one risk (GSST pathology service system) was recommended to be de-escalated from the BAF with a score of 12. Some of the risks had been on the BAF for extended periods of time with minor change in the risk scoring such as workforce and informatics. The BAF was currently being reviewed as well as a review of the boards risk appetite and horizon scanning, which was planned for October 2025. The trust wanted to ensure that risk tolerance was working effectively and the BAF was more dynamic. The trust currently considered their top 3 risks to be workforce, estates and finance. Senior leaders were able to clearly describe the organisations’ top risks consistently.

The trust had a process for gathering, analysing and escalating performance data in an accessible format to the board. The trust produced comprehensive integrated quality and performance reports (IQPR). These included a wealth of data such as waiting times, out of area placements, restrictive practice and complaints. Data was presented in a way that trends over time were easily identifiable. Where appropriate benchmarking was also included. IQPR reports were also presented in alignment to strategic priorities. Individual localities had a IQPR reporting pack that was used to discuss directorate performance. The IQPR process had been in place for a few months with the aim of improving the flow of information from ward to board.

During our assessment of frontline services staff raised concerns around the trusts financial position and the impact this was having on the quality and safety of the care provided. Financial pressures were impacting various areas including staffing, recruitment and filling vacant posts, availability of equipment for therapists, estates, and maintenance. Often staff were reporting that services were not adequately staffed. The concerns around staffing were reflected on the BAF with mitigations in place to improve the trusts position. In the July 2025 board meeting the overall vacancy rate had reduced to 12.1% against the trust target of 10%, turnover was 12% and sickness was 4%. The improvement was due to significant programmes of work being undertaken to improve the position. There were longstanding concerns around medical workforce with a heavy reliance on agency doctors which was costly. Whilst there was a range of improvement work ongoing around workforce it still remained a significant risk for the organisation.

The trust had a guardian of safe working (GOSW) hours who last reported to the board in January 2025. From August 2024 to October 2024 there were 157 exception reports with 78 coming from Core Trainee (CT) Doctors and 79 from Higher/Specialist Trainee (ST) Doctors. This was a slight increase in the number of exception reports by ST doctors compared to previous quarter but lower than previous 3 quarters. There was a fines committee consisting of 6 members including GOSW, 2 CT representatives and 2 ST representatives and the Director of Medical Education. Currently there was no administrator supporting this work. The committee met regularly to review applications received from the trainees. The trust had a risk on the BAF around the changes for Resident Doctors which led to an increase in fines, mostly when the doctors on the ST non-resident on call shifts failed to get 5 hours uninterrupted rest between 10pm and 7am.

The trust had arrangements in place to complete medical appraisals and revalidation. The GMC trainee survey 2023 to 2025 indicated that this trust was within the interquartile range. Therefore, the trust was similar to the average for all UK trainees for overall satisfaction in all 17 other specific indicators. This suggested there was some good oversight and management for GMC trainee staff.

The trust was referring individuals as needed to the Nursing and Midwifery Council as part of its fitness to practice procedures.

Pharmacy staff knew what their roles and responsibilities were, and the pharmacy senior leadership team had good oversight. There was a clear line of reporting for medicine safety risks through the organisation from the Medicine Safety Committee.

There were robust arrangements to ensure that the trust discharged its powers and duties under the provisions of the Mental Health Act 1983 (MH)A, the Mental Capacity Act 2005 (MCA), and Deprivation of Liberty Safeguards (DoLS). The Mental Health Legislation Committee reported quarterly to the board, although not at every meeting. Some discrepancies in the quality of data on community treatment orders (CTOs) had been identified across the directorates, but mitigating action had been taken. We found the recently appointed Executive MHA Lead, who had ultimate oversight at board level, particularly impressive along with the Associate Director of Social Care and Mental Health Law, the Director of Social Care and the MCA lead.

CQC’s MHA monitoring visits from May 2024 to August 2025 commended positive feedback from patients and from carers. The most common concerns raised were consent to treatment and environment issues. The main MHA complaints open in August 2025 related to staff attitudes, medication, safety, allegations of abuse by patients and patient information. CQC had reportedly only received 8 section 61 reviews from the trust over the previous 12 months which was low compared with providers of a similar size. However, the allocation of Second Opinion Doctors (SOADs) following requests by the trust was an ongoing issue for the organisation.

While the Mental Health Legislation Office (MHLO) and MCA teams were mostly very positive about their teams and systems, we were informed of a proposal to centralise the MHAO function and some staff were apprehensive

The trust had arrangements in place to monitor its compliance with the Mental Health Units (Use of Force) Act which came into effect in 2022. The trust had a lead to oversee the work to monitor and reduce the use of restrictive interventions. Trust monitoring had shown a sustained reduction in restraints over time. Reducing prone restraint remained a key priority and whilst the zero-use target was not yet met the trust had made significant reductions. For example, in 2022/23 the trust reported an average of 2 per week compared to 2024/25 which was 0.57 per week. A threshold trigger process was now fully embedded to support the trust to achieve the zero-target goal for prone restraint. As part of this process, all prone restraint incidents were subject to a fact-finding exercise. Any lessons were shared with the ward team and through Directorate-level Reducing Restrictive Practice (RRP) forums and the Trust-wide RRP Committee. Since the last inspection 5 key patient safety interventions were being implemented on wards. These interventions were: Safe wards; Safety Pods and Deltoid Intramuscular injections; Safety huddles; Dynamic Appraisal of Situational Aggression (DASA); and mobile phone charging facilities. The DASA tool was evidence based and was incorporated into the trusts ‘Use of Force Policy’ and ‘Seclusion Policy’.

The trust continued to try to embed a culture of least-restrictive, person-centred care across their services. For example, the Seni Lewis training programme had been implemented since February 2023 with a more recent refresher. The training helped develop the workforce’s knowledge and skills in the prevention and least restrictive management of behaviours that challenge, such as violence and aggression, in the mental healthcare context. The programme had received positive feedback from staff since its implementation and trust compliance was 81%. Staff reported being more confident in utilising de-escalation skills, understanding trauma informed care, human rights-based approaches and using least restrictive practices. However, the inspection of inpatient services found that records of interventions were regularly not completed fully, and this meant that assurance checks might not have all the information needed to ensure these were done appropriately and safely.

The Chief Financial Officer covered the finance portfolio but was also accountable for digital services and environmental sustainability. The chairs of the finance, performance and investment and the audit and risk committees were both senior professionals with experience in public service organisations. The chair of the audit and risk committee was about to step down from the trust and were currently in discussions about recruiting into this position. The finance performance and investment committee had been formed from two predecessor committees in November 2024, and terms of reference had been reviewed and refined after 6 months experience. The committees had reviewed and agreed their forward workplans.

The trust had a track record of delivering its financial plans, through a mix of one-off and recurrent means. The trust had set a balanced financial plan for 2025/26 that required it to deliver £37.1 million of improvements in value. At the time of the assessment the trust had identified an underlying deficit of £23.1 million. The financial challenges in 2024/25 led the trust to put itself into “voluntary turnround” and to pursue financial sustainability as an explicit objective. The turnround programme was led by the Director of Strategic Performance who reported to the Chief Operating Officer. The Chief Operating Officer was also accountable for the estates and facilities functions and led the quality improvement function. The alignment of financial reporting assessments of cost improvement within financial reports had been overseen by the finance performance and investment committee. Further work was said to be required on the data quality and transparency of workforce and financial data.

Whilst the executive team retained strategic oversight of the program there was a Financial Turnaround Board (FTB) which met fortnightly and all ELT members attended. Due to the scale and complexity of the program a multidisciplinary deputies forum was established at the outset to discuss changes, issues and opportunities and make recommendations to FTB. The executive team were proud of the success of its turnround plan and the reductions in its underlying deficit achieved.

The audit and risk committee did not routinely meet with internal and external auditors in private. An external auditor had given the trust a clean audit opinion on its accounts for 2024/25. However, they had for the past 2 years made recommendations that the trust should develop and implement a data quality framework to support its reporting and decision making. The trust had not actioned this as recommended. The internal audit service was shared with trusts in south east London. The opinions given on the quality of the internal control environment for 2024/25 identified a number of reports where there were limited assurances. It also identified the trust had not implemented all high-risk agreed actions within the timescales agreed. The head of internal audit opinion had therefore been abated to “substantial.”

The trust’s capital programme was under pressure with backlog maintenance requirements of around £120 million to get to category D status against an allocated budget of £7 million for 2025/26. The Chief Operating Officer told us that following restructuring and staff changes a capital prioritisation group was implemented to ensure effective use of the capital budget.

Equality and Quality Impact Assessment (EQIA) principles were applied to all financial decisions and formed part of the trusts cost improvement work. Any material change items were referred to the EQIA panel via existing protocols. EQIA were required by NHS Trusts when they were considering health and care service changes focused on financial efficiencies The purpose of these assessments is to enable organisations to show compliance with the requirements of the Equalities Act (2010). Cost improvements were reviewed by the Chief Nurse and Chief Medical Officer and there were examples of where plans had been altered or rejected.

The trust had recognised there had been some challenges in the delivery of high-quality services. For example, there had been a series of incidents across a range of services with some similar themes. In February 2025, the ICB and trust developed a joint improvement plan to address the themes arising from these incidents. The trust provided the ICB with regular updates on delivery against the agreed plan. There was recognition this had driven improvements and strengthened partnership working with the ICB enabling a more joined up approach to quality oversight.

Whilst the trust had substantial cash reserves it had received a capital loan that would become repayable on the disposal of Lambeth hospital. In addition, they faced significant financial risks associated with urgent rectification of building issues including double-running costs and resource implications to maintain the Lambeth site.

The trust had been without a digital and data strategy since 2021. In the September 2025 finance, performance and investment committee they identified it was a critical time to have a clear strategy that set out how the trust would utilise technology, digital tools and data to drive efficiency, productivity and innovation across the trust. A briefing of the strategy was presented to board in September 2025 for board approval, having been reviewed by the finance, performance and investment committee.

Since our inspection in 2021 the trust had had 2 cyber security incidents of its electronic patient record system (EPR) and pathology results system. As a result, the current supplier of the EPR system had made the decision to discontinue the product in 2023, and the trust needed to procure a new system. The trusts new system was not planned to be fully functioning until 2027. Following the decision to discontinue the current product the system was due to cease from December 2025, however the trust secured an extension to February 2026. The current EPR would then have minimal support from the supplier which was a significant risk. The functionality of the EPR also had the risk of degrading over time impacting both staff and workflow. The trust were leaving themselves vulnerable in the event of another cyber incident as they no longer had assurances the system was recoverable. We were not assured that senior leaders were delivering change in a timely manner or within realistic timescales. The work to replace the EPR system started too slowly, and we were not assured there was sufficient time for its implementation. The trust did not appear to consider the impact across the wider trust including issues around data warehouse/informatics, operational implementation and wider affordability. There were differing views from trust staff and other stakeholders of the risk and issues that related to the trust EPR, both in relation to the digital aspects of the system itself and the wider impact on the trust. Despite the significant risks with the current EPR and no system yet being procured to replace it, the trust had not added this as a risk on the BAF.

Cyber threat continued to be on the BAF as a ‘high’ risk and received ongoing monitoring. A report was presented to board in September 2025. The trust had various mitigating measures in place to improve cyber security with the services including staff training, coaching and awareness, and regular reviews and reports to executive leadership.

The Data Security and Protection Toolkit (DSPT) is an online tool which organisations that have access to patient data and systems used to provide assurance to NHS England (NHSE) in respect of their information governance and cyber security standards. Following a mandatory DSPT audit in May 2025 the trust were higher than the NHS Expected Achievement Level in 10 Outcomes, attaining the NHS Expected Achievement Level in 36 Outcomes and below the NHS Expected Achievement Level in 1 Outcome. The trust had submitted an action plan to NHSE for the one area which was below the expected level.

The trusts Emergency, Preparedness, Resilience and Response (EPRR) and Business Continuity approach was embedded within processes across the trust and there was a strong desire to continually improve.

There were many excellent examples of the trust working in partnership and how this supported the delivery of innovative services to meet the needs of local communities and reduce racial disparities in access and experience. However, for people experiencing a mental health crisis the collaborative work with other stakeholders was not always operating well and this adversely affected the experience of people trying to access services. Delays in people waiting in the community for a Mental Health Act assessment was a regulatory breach at the last inspection in 2021 and it remained an issue at this assessment. Whilst considerable work was happening to improve the urgent care pathway further progress was needed. Safeguarding arrangements had been strengthened across the trust. Complaints were not always responded to in a timely manner.

The trust board recognised the importance of its partnership working. This included engaging with integrated care systems, place-based work including primary care, social care and third sector providers and provider collaboratives. Feedback from system partners noted that the current trust leadership was open and willing to work with other stakeholders and other providers. There was recognition that steps had been made to improve relationships with the local acute trusts to effectively support flow. This had been specifically led by the trust’s Chief Operating Officer (COO) through joint site meetings and COO-to-COO relationships. However, sharing timely information with partners particularly when decisions were made regarding service provision potentially impacting care at the front door was an area of ongoing focus for the trust.

The organisation of the trust into geographically based directorates meant leaders were involved in partnership working at a system level and at place. A core ambition of the trust strategy was to expand and enhance the ways in which they work with partners in the local systems to deliver the very best care and support the people and communities they serve. The trust and ICB had shared priorities for mental health around improving access, outcomes and experience for children and young people, a focus on maximising the benefits of earlier intervention and preventative approaches, particularly through new ways of working with voluntary and community sector partners. There was a system-wide focus on reducing health inequalities, specifically for Black patients and communities ensuring a fair and sustainable allocation of resources on a population need basis.

The trust had a Community Care Development Programme in place. This aimed to support the strategic ambition of providing “Outstanding Care’ by improving the quality, effectiveness and consistency of the community care pathway across the trust. Various workstreams were in place currently focused on the design and delivery of the programme. The trust had completed a comprehensive stocktake on the community transformation work with the 4 boroughs which was used to develop the programme of improvement for community care. The trust had completed a centre analysis for the 4 boroughs to give them better insight into the population health, service usage and demand profiles of their local communities by ‘neighbourhood’. This was focused on prevention, reducing inequalities, and improving access, experience, and outcomes. In June 2025, Local Delivery Groups (LDG) were established and were codesigning and developing the programme of care available for their ‘neighbourhoods’. The work aligned with the PCREF (Patient and Carer Race Equality Framework) model, and progress on VCSE (Voluntary, Community and Social Enterprise) partnerships. There was an update presented to quality committee in September 2025 around the transformation work. The trust had also established a Central Working Group to ensure consistency across the trust as the work progressed. The 3 Central Working Groups were: Community intervention; Central intake function; and Children and young people transitions.

Lewisham had been selected as one of the 6 national pilot sites to test the 24/7 community mental health model for adults with serious mental health needs. The Neighbourhood 2 Central (N2C) pilot secured 5 million from NHSE for a 2-year period. The N2C team were leading the development of a co-designed model to implement a 24/7 service model. Between February 2025 and August 2025 there had been streamlined workstreams co-designing and testing the model with staff, people who use services, carers and co-chairs from the Lewisham Independent Advisory Group. The programme implementation group had discussed and agreed the care model. The aim was for N2C service users to receive improved care and interventions by reducing accident and emergency admissions and attendances, Mental Health Act (MHA) detentions and restrictive practice. The pilot had established a number of new interventions including: Access to 24/7 Mountfield Recovery House (MRH) beds to manage crisis; Access to daily crisis slots within the adult community mental health teams to manage crisis and AE attendance; Roll out of mini multidisciplinary meetings for care planning and caseload reviews. There was still a significant amount of work ongoing around the pilot including workforce and stakeholder engagement which had experienced some delays.

The trust was part of the south east and south west London integrated care systems. They were active participants in the South London Mental Health and Community Partnership (SLP). This collaboration was with partners at Oxleas NHS Foundation Trust and South West London and St George’s Mental Health NHS Trust. The SLP brought together clinical expertise, experience and innovation with the aim of improving quality, using resources more effectively, and consistently delivering the best practice mental health care for a population of more than 3.7 million people. The partnership working had contributed to successes over the last 12 months. For example, adult eating disorders enhanced treatment teams indicated a 60% reduction in hospital admissions and reductions in length of stay. The SLP had opened the first south London specialist ward for forensics patients with a learning disability and/or autism to reduce the number of people cared for outside south London.

The pharmacy team maintained strong external relationships, including collaboration between the trusts Integrated Medicines Optimisation Committee (IMOC) and King’s Health Partners (KHP) that enhanced the integration of mental and physical healthcare, research, and education across Southeast London. Pharmacists also linked in with national specialist teams, for example national CAMHS teams and teams for rare diseases to offer support advice.

South London Listens is a mental health prevention and recovery partnership programme funded through the south London ICB and the trust. It was a collaboration of the 3 south London mental health trusts, 9 local authorities and over 150 community organisations working to prevent a mental health crisis as a result of Covid-19 and support community recovery. Since 2021 South London Listens listened to over 10000 people across south London, refining priorities and co-developing new pledges of action from NHS and local authority leaders. This included developing plans to improve engagement with young people on the CAMHS waiting list and tackling the impact of housing on health and wellbeing. Following an innovative South London Listens pilot, the trust is rolling out a new full-time role in Lewisham working to increase access to mental health help for refugee, migrant, and diaspora communities. They had also been successful in securing funding from the Maudsley Charity for the EarlyBIRDS projects in Lambeth and Croydon. 'The trust will be working with community and academic partners to develop community-based single-session interventions (SSIs) for vulnerable 16-19-year-olds in challenging circumstances.

The trust and SLP were in discussions with providers in both south east London and south west London to develop local mental health provider collaboratives. These partnerships would work within their respective ICB footprints and focus on maximising the benefits of provider collaboration to improve local mental health services.

In 2024, the trust established a new children and young people’s partnership named the King’s Maudsley Partnership for Children and Young People (KMPCYP). The purpose of this was to facilitate clinicians and researchers to work more closely together to find new ways to predict, prevent and treat mental health disorders for children and young people. The partnership was supported by the Maudsley Charity, between the trust’s children and young people's clinicians and children and young people related researchers and academics from King’s College London’s Institute of Psychiatry, Psychology and Neuroscience (IoPPN). The partnership will eventually be based in the purpose-built Pears Maudsley Centre. Both clinical and academic teams will be co-located with the aim of enabling new levels of collaboration and partnership working. The centre will include a purpose-built clinical research facility to enable children of all ages, to participate in research to identify mechanisms that underpin mental health and neurodevelopmental disorders, and to implement and monitor novel interventions.

The trust had a partnership with King’s Health Partners’ Mind and Body programme which was driving forward the key strategic priority around the integration of mental and physical health. In 2023/24 services called Consultant Connect was developed with support from Mind and Body and was embedded into the trust's services. Mind and Body had also been supporting improvements in physical healthcare offered in community mental health teams. Mind and Body worked in close collaboration with the trust physical health team and community transformation programme, King’s Health Partners, the south east London ICB and Oxleas NHS Foundation Trust.

The trust had been a central partner in the co-design and delivery of the new National Children’s Gender Service, alongside Guy’s and St. Thomas’ NHS Foundation Trust and Great Ormond Street Hospital. The service officially launched in April 2024, following the closure of the Tavistock and Portman Gender Identity Development Service. The trust chief executive and programme manager played a visible leadership role in the strategic planning, risk management, governance, and national coordination of the service to enable mobilisation and implementation.

The trust delivered the South East London Suicide Bereavement Service with its partners in South East London Mind and Mind in Bexley. This service had won a HSJ partnership award. The trust ran an annual conference and service of remembrance to mark World Suicide Prevention Day. The day was focused on reducing the stigma, raise awareness and start meaningful conversations around suicide. The event was jointly run by the trust, South East London Suicide Bereavement Service partners, South East London Mind and Mind in Bexley. The conference showcased important work in the field of suicide prevention and included lived experiences of people who had lost a loved one.

Various Healthwatch teams told us that they engaged with the trust on a regular basis. They had been consulted around strategy and other co-production. Healthwatch teams fed back that they found trust staff to be approachable and professional. One Healthwatch said the trust had provided detailed feedback on a transgender and non-binary health experiences report where they cited many recommendations for partner organisations and the trust had taken these into consideration for their services.

There was a section 75 agreements in place between the trust and Croydon. The one previously held with Lewisham had recently been terminated. The 4 local authorities were responsible for approved mental health professionals (AHMP), and they worked within their boroughs to assess their own residents. The trust did not hold responsibility for the management of AHMPs. There was a pan London app for Section 12 doctors. This was used by AMHP to access Section 12 doctors where they were required for an assessment. There had been difficulties obtaining AMHPs and Section 12 doctors in the urgent and emergency care pathway. This was particularly in the early hours of the morning and often could cause delays for assessments.

This inspection found ongoing significant delays for people waiting in the community for Mental Health Act assessments. This had been a breach at the previous inspection in 2021.

One section 136 suite served as a hub for the trust at the Maudsley hospital site. This hub was supported by partnership working with the London Ambulance Service and the police. This could be busy, which impacted on the number of assessments that could take place there. There was a focused visit by CQC Mental Health Act reviewers to the 6-bed centralised Health-based Place of Safety (HbPoS) at the Maudsley Hospital on 10 June 2025. This identified that the HbPoS did not accept patients detained under sections 2 or 3. As a result, there were frequent breaches of the 24-hour time limit for detention under section 136, meaning people were held in the HbPoS after their detention under section 136 had expired. AMHPs also stated that they were no longer permitted to bring patients subject to section 135 to the HbPoS and that the only way to avoid section 136 breaches would be to increase bed capacity. However, following the assessment the trust told us that the HbPoS policy states that it can be used for 135 warrants. However, where possible they try to use inpatient beds. The trust also provided evidence showing section 135 patients were using HbPoS when needed.

From April 2024 to March 2025 there were 481 admissions to the HbPoS. The vast majority of these, 446 in total, involved breaching the 24-hour time limit for detention under section 136. The majority of the breaches, 382, were over 36 hours. In addition, the reviewers found that there was no direct access to outside space and fresh air which was not in line with the Mental Health Act Code of Practice. Managers told CQC that a bid for funding had been submitted to the trust charity to address this. There was also no evidence of staff informing people of breaches and that the legal authority for administering medication to people in the HbPoS and for detaining people beyond the 24-hour limit was unclear. The trust informed us of a new dashboard to display HbPoS information which had recently been introduced, together with further discussion of medication and the trust’s jurisdiction, led by the Chief Nursing Officer.

There had also been an increase in the number of people being detained under the Mental Health Act whilst under the care of local acute hospitals. The trust had service level agreements with Lewisham and Greenwich NHS Trust, Croydon Health Services NHS Trust, Guy’s and St Thomas’ NHS Foundation Trust and King’s College London. In total, there were 286 uses of the MHA in acute hospitals in Q1 with 121 (42%) patients subject to section 136. Of the 286 patients, 228 (79%) were known to the trust. This was a significant increase on previous quarters and there were reportedly more patients staying longer on a section in the acute hospitals.

Senior leaders understood waiting times in emergency departments was a key area of focus for the trust. Whilst there had been some improvements around 72 hour waits there was still work to do, particularly around 12 hour waits where the trust was performing worse than most of the London mental health trusts. The trust had established the Acute and Urgent Care Programme aiming to improve the quality, effectiveness and consistency of the urgent and acute pathway across the trust. The programme comprised of workstreams that supported the acute and urgent care transformation agenda. The workstreams were grouped under two core areas which were inpatient quality and flow and 24/7 access. The teams working on the inpatient quality programme were advancing with clear deliverables, milestones, and impact measures. Additionally, the working group reviewing the 24/7 urgent and emergency care offer had established some initial recommendations regarding the crisis assessment team and the adult recovery house. These recommendations included extending the current contract and identifying the new permanent location for the adult recovery house which was allocated for the Lewisham 24/7 community pilot starting in September.

The trust were represented in multi-agency partnership safeguarding work. The associate director of safeguarding, trust wide and directorate safeguarding leads, CAMHS safeguarding practitioners and directorate managers represented the trust at multi-agency meetings and case conferences. These included the Safeguarding Children Partnership (SCP), Safeguarding Adult Board (SAB) and subgroups in Croydon, Lewisham, Bromley, Southwark and Lambeth. The director of social care and associate director of safeguarding attended Integrated Care Boards, SCPs and SABs executive meetings.

The trust previously identified its safeguarding approach required strengthening and improving, including how it worked with partners. Safeguarding governance had been on the trusts BAF and recently was stepped down to the executive risk register due to phase 1 of the trust-wide safeguarding programme completing. The trust had strengthened its safeguarding team and infrastructure to ensure statutory responsibilities were met and ensure safeguarding remained a priority across all services. There was now a centralised safeguarding team and a generic email which provided a faster, more co-ordinated response to all staff safeguarding queries and partnership information requests, through improved information sharing between teams in different boroughs. The trust had appropriate links with safeguarding boards and child death overview panels within their geography. They contributed to serious case reviews and level 4 safeguarding investigations when required. Trust wide compliance with safeguarding training was meeting the trust target of 85%. However, safeguarding children level 3 compliance was below the 85% trust target (82.2%). There had been a focussed effort from the centralised safeguarding leads and directorates to increase the availability of teaching sessions to improve compliance. Significant improvements had been made in relation to safeguarding supervision during 2023/24 and trust wide compliance was above 75%.

There was a risk the trust would not meet the October 2025 deadline in implementing Phase 2 of the NHS England Child Protection Information Sharing (CP-IS) System rollout. This would potentially impact Child and Adolescent Mental Health Services (CAMHS), Perinatal Services, Mother and Baby Unit (MBU) and other trust services for children. CP-IS will help health and social care workers share information securely to better protect children and young people who are known to social care because they are looked after or have a child protection plan. CP-IS links information technology (IT) systems across health and social care in England to help organisations share information securely. The trust had gaps in obtaining safeguarding children data electronically on the electronic patient record system.

The trust were working with Croydon Drive Project as one of the pilot areas in England and Wales piloting interventions supporting perpetrators of the civil Domestic Abuse Protection Order (DAPO). DAPO is a court order issued to provide long term protection for victims of domestic abuse. DAPO has the ability to impose positive requirements and mandate perpetrators to take action.

The trust had processes to respond to complaints from people using services. We met with the trust complaints team and reviewed 5 complaints. There was a complaints team which had administrators and complaints investigators. Whilst investigators processed the complaints, staff in the operational directorates were required to handle the investigation with the support of the complaint’s investigators.

The corporate complaints team had been funded to have more resources. New staff commenced in April 2024 and were supporting operations in writing response letters to complaints. The trust had piloted some complaints training but still did not offer this to all staff who were involved in complaints work.

At the time of our assessment, the trust had a 2-tier turnaround for complaints. For normal complaints, the trust had 50 calendar days to respond and this was extended to 90 days for complex complaints. The trust was not consistently responding to complaints within agreed time frames resulting in a significant backlog. The complaints team recognised there was still work to do around investigation timeframes. Complexity of concerns was highlighted as one of the main factors impacting this. They identified the need to do some work on upskilling operations teams around complaints investigations. Performance data relating to complaints was presented to the quality committee as part of the ‘Lessons Learned’ integrated report. The trust received 196 complaints in quarter 1 of 2025/26 which was an increase on the 185 reported in quarter 4. The complaints team had completed a project developing new complaints posters for patient areas to encourage service users and carers to make complaints. The new larger posters were developed in collaboration was service users and carers. This was an area of focus for the trust to ensure they were learning when things went wrong.

The complaints team reviewed investigation reports and response letters to complainants, which were authorised by the chief executive. Processes were in place ensure learning from complaints was shared. The sample of complaint responses we looked at demonstrated the trust understood duty of candour and were open and honest with patients. They were delayed in their responses and for the 5 complaints we reviewed it was not always clear what elements were upheld or not upheld. However, feedback from the service level assessments around complaints were that they were detailed and responded to effectively.

Learning, improvement and innovation is an area of strength for the trust. There is a well-established research programme engaging staff from a range of professional backgrounds. Co-production with people who use the trusts services, and their carers had progressed since the last inspection with innovative developments in the communities served by the trust. The trust had continued to embed its use of quality improvement methodologies in both trust wide and smaller improvement projects. The trust had been a pilot for the Patient Carer Race Equality Framework, and this was now supporting improvements in accessing services for Black service users. The trust had a mortality review framework which was working effectively identifying trends. The trust had implemented the Patient Safety Incident Response Framework, however there was a backlog of investigations following serious incidents. Plans were being developed to complete this work in a timelier manner so learning could be shared and embedded.

The involvement of people who use services and, in their design, delivery and evaluation had been an area of focus at the trust. This had progressed since the last inspection, particularly in the directorates linked to a geographic area. This report provides some highlights but is only a small sample of the great work underway.

There had been recent changes in the leadership of the involvement work. The Patient and Public Involvement (PPI) collaboration, service user and carer involvement and peer support was moved to the strategy and transformation directorate in June 2025 with the Director of Strategy and Transformation as the new executive lead. The trust were planning a stocktake and review of service user and carer involvement alongside the 2026 strategy refresh. The trust had established a service user and carer reference group to support the strategic planning and provide feedback on the development of the trust's annual goals.

The trust had successfully completed its review of ‘Triangle of Care’ which focused on how inpatient services engaged families and carers. The trust remained committed and completed its updated evaluation with the Carers Trust in June 2024. The trust retained the Triangle of Care Star 1 for inpatient and crisis services.

Involving service users, carers and families was also an area the trust focused on when working with partner organisations. For example, they had relaunched the Croydon Families and Carers Mental Health Forum, which was in partnership with Croydon Council, MIND in Croydon, Carers First and Off the Record. The Forum met monthly providing a voice for carers/families of people with mental health needs to inform the work of partner organisations.

The Lewisham Families and Carers Mental Health Network had been established with carer involvement and was now a partnership between the trust, Lewisham Council, the ICB and the borough service supplier. As part of the Lewisham Pilot of 24/7 community services, the trust had reviewed the carer champion role and team responsibilities for supporting families and carers. The trust was in the process of drafting team responsibilities in collaboration with the carers lead.

The trust, through South London Listens, had developed the CAMHS virtual waiting room and improved working with parents and families to support engagement for those on the CAMHS waiting list. Ongoing work was taking place to further develop this service.

The trust remained focused on improving carer involvement and examples of this included: carers being co-facilitators in Carer Awareness Training (Lambeth and Southwark); Involvement of carers in reviewing welcome packs; The Annual Family and Carer Listening event supporting families and carers to discuss carers issues and feedback to the trust​.

The trust had adapted the HOPE(S) model to support teams to develop action-oriented plans to end long-term, and break the cycle of, repeated seclusions and segregations. The HOPE(S) model was a human rights-based approach to working with individuals in segregation developed from research and clinical practice. The clinical model was developed by Mersey Care NHS Foundation Trust.

For September, the trust had received an overall segment rating of 3 and this placed them at 34 out of the 61 mental health and community trusts across the country. The areas of focus in the NOF were aligned to those that the trust was already focusing on. This included length of stay, support to under 18s, NHS Staff Survey score for raising concerns and proportion of urgent referrals to crisis care teams with first face to face contact within 24 hours.

There was ongoing weekly reporting on safety data to the Executive Leadership Team safety huddle using the Deming dashboard, and directorate safety leads reviewed this data within their own directorates. The Deming dashboard allowed the trust to look at trust-wide data, directorate level data and team level data. The trust were working with quality improvement and informatics colleagues to support directorates to annotate changes in Deming.

Ongoing work was underway to further develop the dashboard, enabling analysis of specific restrictive interventions, such as seclusion and rapid tranquillisation by ethnicity groupings. The trust told us they were also exploring opportunities to break down the data by gender, to support a more detailed understanding of patterns and potential inequalities across groups.

The trust continued to develop and embed quality improvement approaches across the trust in co-producing with patients, staff, carers and families, and the communities they served. The trusts improvement service based within the quality centre was focused on enabling improvements across the trust at all levels from strategic trust wide improvements to localised team improvements. The improvement team were working on developing and embedding quality improvement (QI) approaches across teams and directorates.

The most recent report to quality committee reported the team had supported 139 projects using the adopted QI methodology. The service had delivered learning and developmental teaching sessions for staff to educate and embed the improvement methodology. There were various examples of QI work including one transforming ‘enhanced observations’ into ‘enhanced care’ which supported the trusts strategic goal of improving patient experience, reducing restrictive practices, and achieving financial sustainability. The project aimed to reduce the volume and duration of enhanced care episodes, improving staff confidence and enhancing patient engagement.

The trust had embedded the blanket Restrictions Review Process (RRP). There were regular reviews conducted within the directorates in the RRP working group and overseen by the RRP committee. This process included a 3-stage test to ensure a human rights-based approach, supporting the goal of further reducing restrictive practices across all services.

The trust was part of the 24-month national culture of care improvement programme supporting organisations to embed 12 standards of inpatient care. These were co-produced nationally with staff and people with lived experience. The improvement team were managing 6 workstreams and providing additional coaching towards supporting them to embed the standards.

An area of progress in the trusts quality improvement work was the increased use of DIALOG as an outcome measure. DIALOG is a structured patient reported outcome measure that is completed at the start of a new assessment episode and agreed intervals. There had been significant progress but there was more to do. The current caseload for adults of working age showed 21.7% of current patients (with an episode status of accepted or waiting) had a completed DIALOG or had been offered one and 4.8% of current patients (with 2 or more attended contacts) had a pair of valid DIALOGs.

The trust had introduced team improvement huddles which were short (15 to 30 minute) weekly multidisciplinary huddles around an improvement board. The purpose of improvement huddles was to give teams protected space to think together to solve problemsand identify quick wins and ideas to test using Plan-Do-Study-Act cycles (PDSA). Over 30 teams in the trust were already using improvement huddles to drive change. The trust had highlighted improvement huddles during the trusts most recent QI week.

The trust was a Patient Carer Race Equality Framework (PCREF) pilot and continued to work within this programme. They also contributed to the local, ground-breaking work such as Birmingham Lewisham Black African Caribbean Health Inequalities Review (BLACHIR) that identified significant opportunities to improve outcomes for those communities. This was a significant area of challenge in Lewisham and mental health services were a key component of the work to address inequality.

The trust were using place based PCREF data to understand the issues for their global majority service users. For example, Black service users accounted for high percentages of mental health detentions which was disproportionate to their population representation. Black service users also experienced restraints at a rate nearly double that of white service users (11.29 vs 6.04).​ This information was helping the directorate leadership to identify areas to focus on to drive improvements for service users. For example, the trust had made measurable progress on closing the early intervention gap for Black patients. The trust reported that over 77% of Black service users were now accessing early intervention treatments sooner compared to 60% in 2021. This was against a London average of 68%. The trust had achieved this through a ‘Triple Leadership’ model where each borough formed local teams, co-led by staff, service users and community representatives. In Lewisham teams designed borough specific solutions, such as the ‘Through Our Eyes’ anti-racism training, which reframed how staff understand and respond to Black service users’ needs.

The pharmacy team demonstrated a strong commitment to continuous improvement through research, innovation, and quality initiatives that delivered measurable benefits locally, nationally, and internationally. Notably, several academic publications on clozapine optimisation, including the use of genetic testing to support early and safe initiation, and the adoption of finger-prick capillary sampling to simplify monitoring. Evidence gathered by the pharmacy team contributed to the development of updated clozapine monitoring regulations introduced by the European Medicines Agency. The team also promoted the use of long-acting and very long-acting antipsychotic injections to enhance clinical stability, reduce relapse rates, and help patients transition safely back into the community. Innovation was a key strength, with staff encouraged to develop research and service improvement skills, supported by senior pharmacists. However, limited strategic support and funding stifled the scalability of these initiatives. Staff expressed concerns that their contributions were undervalued at trust level. Staff told us the trust were not interested in quality, only in numbers.

The trust had a well established research department which was involved in national research programmes. The teams also connected with local universities. The trust continued to focus on embedding research across its services and had created the role of Research Champions (RC) to raise awareness of ongoing research studies to people using services. The RC role also supported the trust in achieving its strategic aim of being a catalyst for change. In 2021, the trust had identified 182 clinical teams and the aim was to have a RC in each team. The trust were currently meeting this for 39% (71) of their clinical teams.

The trusts Take Part in Research (TPiR) webpage was launched in July 2023

and publicly listed research projects which they were currently recruiting to. It allowed patients, carers, staff and the public to browse studies and contact the research teams directly for further information. The trust had also established ‘Consent 4 Contact’ (C4C) around research and 27,000 service users had signed up for this since it began.

In the year ending March 2024, the trust was the number 1 mental health trust in England for the number of research studies and participants with 5889 people recruited into research and had 97 open NIHR portfolio studies. However, they understood there was more work to do to ensure offers of research was equitable for all service users. They were focused on removing barriers to taking part in research and increasing diversity and access to research. The trust established and led the Building Race Equity and Diversity in Research Network (BREaD). This was used toshare good practice on race inclusion, diversity and equity in research with the NHS and universities. BREaD also linked in with the Patient and Carer Race Equality Framework (PCREF).

The Service User Research Advisory Group (SURAG) provided insight to the research and development team during monthly meetings. SURAG identified potential areas of development for the trust . For example, SURAG identified the need for the trust to improve how they shared research updates of research findings with participants. The trust conducted an audit of recently closed studies to see how they communicated with their participants. The trust now shared research outcomes on the Take Part in Research website. They also launched a research round-up on the trust website to share research stories and impact. Despite the extensive research and improved communications, research leads when interviewed, struggled to clearly articulate how the research was impacting the care and treatment for people using the trusts services. The one exception was the clinical pilot into the use of three monthly (instead of monthly) clozapine injections, where during the inspection the staff spoke about the benefits for service users.

During 2024/25 the trust participated in 2 national clinical audits and 1 national confidential enquiry which covered the relevant health services provided by the trust. There was trust wide local audit programme of 31 audits across wards, crisis and home treatment teams, community mental health teams and specialist teams for services provided to all ages. Managers completed the audits using an online inspection tool which allowed them to identify and address quality variations in the fundamental standards of care. This included audits on clinical safety, environmental safety, physical health checks and infection, prevention and control.

The trust had introduced the Service Quality Review (SQR) which was a process designed to improve clinical care across the organisation. This involved reviewing services against clinical quality standards to identify areas for improvement in relation to CQC fundamental standards of care. The trust had introduced a dedicated Service Quality Reviewer role into the nursing directorate. From January 2024 to March 2025, a total of 90 SQRs had been completed across both inpatient and community services. Where actions were identified these were placed on the SQR tracker until the required improvements were made.

The trust were members of a number of quality peer review and accreditation networks from the Royal College of Psychiatrists across inpatient and community services. The trust had 11 accreditations and were working towards accreditation across other inpatient and community services.

The trusts mortality review group (MRG) was responsible for reviewing and learning from deaths, aiming to improve patient care and reduce avoidable mortality. The MRG reviewed data on patient deaths, including local mortality reviews, to identify patterns and trends. The MRG provided assurance to the trust board and other relevant bodies on patient mortality based on the review of care received by those who died.

The trust had systems in place to learn from the deaths of people with a learning disability or autistic people (LeDeR) who were receiving services from them. Learning from LeDeR reviews was shared across the trust and with other partners to help reduce the health inequalities for people with a learning disability or autistic people.

The trust had moved to the Patient Safety Incident Response Framework (PSIRF) in 2023. This was in line with NHS England guidance on how to respond, learn and improve patient safety. The trust had governance procedures underpinning the trusts PSIRF approach. Where an incident was reported as significant or significant learning, the incident was escalated to the quality matters meeting for further review and to agree a proportionate response type. Where incidents were identified as requiring learning, they triggered a full Patient Safety Incident Investigation (PSII). Information around PSII was shared with clinical governance teams and heads of nursing and quality at a monthly Safety Events Review Group (SERG). This was then fed up into the patient safety committee and the Executive Leadership Team (ELT) Safety Huddle, as appropriate.

The trust previously had a backlog of legacy cases under the Serious Incidents Framework (SIF) and there were 3 legacy ‘Level 2’ investigations remaining. The trust’s Patient Safety Incident Response Plan (PSIRP) set out the ambition that PSIIs should be completed within 6 months, however this was not a mandated timeframe. Since PSIRF launched the trust expanded the patient safety team to optimise the resource dedicated to producing timely and high-quality PSII reports. Despite this, all investigations currently under review were not meeting the trusts 6-month investigation timeframe. The patient safety team were currently working with a quality improvement coach to action the delays in investigations. The improvement plan set out a series of improvement measures including standardisation of the process, performance monitoring and staff engagement. However, investigations were often complex and required multiple internal/external stakeholder involvement. This impacted the timeliness of the investigation report.

In 2023 the trust gained accreditation with the Serious Incident Review Accreditation Network (SIRAN) from the Royal College of Psychiatrists. The trust underwent an interim accreditation review in November 2024. SIRAN is a quality improvement and accreditation network for mental health organisations' serious incident processes. The trust updated SIRAN on the changes made to trust safety processes in the light of PSIRF. The review verified that the trust continued to meet SIRAN standards and was making good progress with actions resulting from the last review.

The trust had a dedicated infection prevention control (IPC) team. They last reported to the board in May 2025. The team provided advice to teams or individual staff and provided trust wide IPC governance. A range of audits had been completed to monitor and review compliance with IPC. Trust wide, IPC mandatory training was above 85%. The IPC lead was a member of the EPRR group and had a refreshed pandemic plan. The team had suggested the trust conduct an exercise around measles cases, which was supported by the COO. This took place at the Bethlem site and supported teams to successfully manage a case of measles.

The trust had been nominated for or won a number of awards. For example, Secure Settings Service User Carer Advisory Group (SUCAG) had been awarded the Royal College of Psychiatrists’ 2025 Award for Patient/Carer Outstanding Contribution to Psychiatry. This was national recognition around the group’s pioneering work in embedding lived-experience voices at the heart of forensic mental health services. SUCAG was a monthly hybrid forum co-led with a lived experience practitioner. The meeting supported inpatients, community service users, carers, and staff to come together to shape service provision through meaningful co-production.

The trust had also been shortlisted for Trust of the Year and Widening Participation and Collaboration at the Capital Clinical Support Worker Awards in 2025.

Mandatory training completion rates were good across all localities with all achieving a compliance rate above the trust target of 85% or higher although there was some variation across different modules and specific teams. Compliance rates for appraisal were good at 92.3%.

The trust demonstrated a commitment of working towards improved environmental sustainability. The Green Plan was in the process of being updated. The governance arrangements were in place to oversee this work. Initiatives were in place to promote sustainability in the trust. The financial challenges being faced by the trust meant they were focusing on actions which were realistic and achievable.

The trust had a Green Plan, in line with national guidance, and was in the process of updating this in line with national guidance and the trusts goals. Leaders acknowledged the importance of ensuring Green Plan goals were being delivered upon, and there was clear evidence of oversight. The trust had a sustainability forum which acted as the principal body for developing and implementing the policies and actions outlined in the Green Plan. This was supplementary to the operations board meeting and took place every four months, chaired by the chief of staff. The forum monitored progress against the plan and updated the finance performance and investment committee who had strategic oversight of the plan. The committee updated the board on progress against the actions. There was also a clinical steering group focused on embedding net zero care principles into the planning and delivery of clinical services. This was led by the clinical lead for sustainability. The clinical sustainability working group had been established to encourage sustainable behaviour in clinical settings, such as wards.

A sustainability report was included in the trust’s annual report, along with an annual summary of progress against the plan. The trust also completed quarterly greener NHS returns to report on broader sustainability progress, alongside the annual Estates Return Information Collection (ERIC), which included updates on energy, waste, and water.

The trusts draft updated Green Plan identified 3 main priorities. Priority 1 was monitoring and reporting on sustainability performance. This focused on the need for the trust to improve data collection and verification to understand their carbon footprint better. Priority 2 was a commitment to reducing carbon dioxide, greenhouse gas (GHG) emissions and environmental impacts associated with the delivery of their mental healthcare services. Priority 3 was around embedding sustainability awareness across the trust. The sustainability leads for the trust had recently presented the draft Green Plan to the finance performance and investment committee. The committee's recommendations were currently being considered and the plan was for the draft to go back to committee and then to board for final approval. There was some further work to do around understanding what metrics would be used to measure the trusts performance against the objectives outlined in the plan.

The trust was spread over a large geographical patch. Leaders recognised there had been challenges in engaging staff across the trust and that there was more to do in this area. Leaders were concerned that staff may not be aware of net zero goals or their role in contributing to these. The trust aimed to develop quality improvement projects that promoted sustainability and was aware of the need to focus on efficient models of care. To improve engagement and information sharing around the Green Plan and net zero goals the trust was identifying green champions. Sustainability was discussed during inductions and there were teaching sessions for medical staff and information being shared during the trust broadcast.

There was a clear connection between the sustainability projects within the organisation and the trust’s core purpose of delivering mental health services. We heard clear examples of projects that whilst advancing sustainability also connected to and promoted mental health. For example, some services were doing nature walks with service users as part of their recovery. In Lewisham, the trust had begun engaging with the biodiversity lead at the local council to think about a conservation project in the local community. The trust had improved access to on-site active travel facilities such as introducing bike shelters at the Ladywell Unit and installing a bike shelter on the Bethlem site. They had also closed a car park to encourage staff to use other methods of travel.

Sustainability leaders recognised the pharmacy department positive contribution to the trust's sustainability agenda. Medicines sustainability featured in the medicine’s optimisation strategy 2025/26. The pharmacy team had completed a number of initiatives including introducing a shared email inbox to reduce digital burden and improved staff psychological wellbeing, optimising evidence-based asthma inhaler prescribing in line with NICE guidance, improving patient outcomes and supporting environmentally sustainable practices.

The trust was clearly engaged with the ICB around sustainability, with acknowledgement of their contribution to south east London ICB Green Plan. This incorporated actions from individual south east London trust Green Plans into a regional green plan. However, the ICB acknowledged further progress was needed.

Within some areas, such as estates, travel and transport, there was a clear understanding of where reduction in emissions could be achieved. For example, the trust’s identified estates as a significant consumer of energy, making it a major contributor to the organisation’s carbon dioxide emissions. Various projects were ongoing to reduce this such as the ongoing LED lighting installation across the trust’s estate and the use of passive infra-red light sensors where feasible. The trust had been awarded grant funding for a heat decarbonisation plan for the Bethlem site. The plan provided a route map for the Bethlem site to transition towards net zero emissions by 2040. However, all the solutions proposed within the plan to decarbonise the current heating systems were only feasible if the electrical infrastructure on the Bethlem site was upgraded. The costs to decarbonise the Bethlem site identified there were significant financial challenges to achieve net zero. The trust recognised that some of the NHS England sustainability aims required significant investment and with the trusts current financial position it would not be possible for the trust to meet them. Therefore, the trusts plan was to focus on actions that were realistic and achievable within the current financial and operational context.

The trust had accreditation for ISO 14001:2015, an international standard that supports effective environmental management by helping the trust reduce its environmental impact and comply with relevant legislation.​ Additionally, the trust was certified under ISO 50001:2011, which focused on energy management. This standard enabled the trust to conserve resources and address climate change through a structured Energy Management System (EnMS).​ The British Standards Institute (BSI), a certified ISO auditor conducted annual audits at the Bethlem and Maudsley sites to ensure ongoing compliance with both standards, allowing the trust to maintain its certifications.