South London and Maudsley NHS Foundation Trust

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

All patients’ risk assessments were completed and up to date using a structured judgement tool. The ward was visibly clean, tidy and appropriately maintained. Staff put protection plans in place to keep patients safe. Staff were generally up to date with their mandatory training. They had received training in safeguarding, knew how to recognise potential abuse and made appropriate referrals to the local authority safeguarding team.

We saw appropriate examples of learning from incidents, and actions being put in place to prevent recurrence. All staff we spoke with, were aware of incidents that had taken place in the last year. Ward managers reviewed incident reports and completed a fact finder report where required to ensure that rapid learning could be put in place. Where needed a more detailed incident investigation was put into place. Incidents were discussed at handover meetings, in team meetings and supervision sessions and regular bulletins were distributed to highlight recent incidents and learning.

There had been no incidents of restraint or rapid tranquilisations on the ward in recent months. Staff followed policies and procedures for the use of observation in accordance with trust guidance and completed targeted searches if there were specific risks identified. There were systems in place for staff to follow before patients went out on unescorted leave. However, we found that there was sometimes little detail recorded of staff engagement recorded with patients before going on leave and on return from their leave, even when there were particular risks identified. In one case it was not clear how staff had come to the decision to give a patient an extra 2 hours before notifying police of their absence.

For risks identified, patients had care plans in place to address these. However, in the case of a patient with diabetes, and a patient who experienced seizures, the medicines specified in the care plans were not up to date with the current medicines prescribed.

Staff told us that it was sometimes hard to manage risk and patient support during the day, particularly at weekends when there were fewer members of the multidisciplinary team available to assist. Senior managers advised that following the inspection, they had added an extra staff member shift at weekends.

Staff adhered to infection control principles, including handwashing and wearing appropriate personal protective equipment such as disposable gloves. Staff ordered, stored, dispensed and disposed of medicines safely. Staff signed when they administered medicines or recorded why not, in accordance with trust policy. Patients prescribed medicines (such as clozapine) where levels could be affected by smoking were given smoking diaries and had plasma levels checked to ensure medicine levels were within range.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We saw appropriate examples of learning from incidents, and actions being put in place to prevent recurrence. All staff we spoke with, were aware of incidents that had taken place in the last year.

Staff knew what incidents to report and how to report them. Ward managers reviewed incident reports and completed a fact finder report where required to ensure that rapid learning could be put in place. Where needed a more detailed incident investigation was put into place. Incidents were discussed at handover meetings, in team meetings and supervision sessions. Staff were aware of the regular bulletins the trust sent to highlight recent incidents and learning. They gave examples of learning from incidents including more detailed checks on admission, lone working precautions, carrying alarms, ratios of male and female staffing, and improved handover information. Following a recent incident, staff had been provided with further reflective practice sessions arranged every 2 weeks.

Duty of candour is a legal requirement, which means providers must be open and transparent with patients about their care and treatment. This includes a duty to be honest with patients when something goes wrong. Staff were aware of the need to always be open and transparent, including after an incident.

Two of the beds on the ward were designated assessment beds. The average length of time a patient spent on the ward was 686 days as of 29 November 2024. The average length of stay since admission (on another forensic ward) was 973 days. Staff noted that there were some delayed discharges from the ward due to difficulties finding appropriate accommodation that met people’s needs.

The forensic service held a meeting each week to discuss referrals, transfers and discharges. Transfers from the ward could occur if a patient required seclusion or a higher level of supervision, and if there was safeguarding incident between two or more patients on the ward. Staff ensured that when they transferred or discharged patients that this was always at an appropriate time of day, except in the event of an emergency.

There had been no incidents of restraint or rapid tranquilisations on the ward in recent months.

Staff were trained in safeguarding, knew how to make a safeguarding alert and told us that they did so when it was appropriate. At the time of the inspection, all staff were trained in safeguarding adults, and only one staff member was due to complete training in safeguarding children.

In the year prior to the inspection (1 December 2023 – 29 November 2024) 4 safeguarding concerns were raised by the ward relating to three different patients. All of these incidents related to patient assaults by other patients on the ward and led to protection plans being put into place.

Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies. Staff could give examples of safeguarding alerts they had made.

Children visiting the service were not permitted on the ward. Instead, patients could see children, if this was identified in their risk assessment as being appropriate, away from the ward in a visitors’ room.

Staff followed policies and procedures for the use of observation. Staff completed observation records for each patient in accordance with trust guidance and completed targeted searches if there were specific risks identified. Staff applied blanket restrictions on patients’ freedom only when justified, such as items that they were not allowed to bring on the ward.

Staff completed the HCR-20 (Historical, Clinical, and Risk Management assessment)a structured judgment tool used to assess the risk of violence, for each patient. This was completed within 3 months of admission and then reviewed regularly as needed. We saw detailed risk assessments in place for patients on the ward.

There were systems in place for staff to follow before patients went out on unescorted leave. Staff recorded what patients were wearing and checked on how they were feeling and presenting before going out. However, we found that there was sometimes little detail recorded of staff engagement recorded with patients before going on leave and on return from their leave, even when there were particular risks identified.

For one patient on restricted conditions, staff had waited for a 2-hour ‘grace period’ before contacting the police to notify them that they did not return from their section 17 leave in November 2024. It was not clear how they had come to this decision, and who was involved in making it, despite this being an area for learning following a serious incident on the ward.

For risks identified, patients had care plans in place to address these. However, in the case of a patient with diabetes, and a patient who experienced seizures, the medicines specified in the care plans were not up to date with the current medicines prescribed.

Recording and management of risk on the ward largely used a stratification approach (RAG rating). Managers noted that the trust was moving towards a more dynamic risk assessment process for patients’ risks of self-harm or suicide.

Staff undertook regular risk assessments of the care environment and recorded and reported on any areas that required attention, for example broken items of equipment.

The ward layout included several blind-spots, which staff were aware of (these were not mitigated by use of mirrors), but staff managed these by hourly environmental checks and appropriate risk assessments of patients.

There were some ligature risks in the ward, including door handles and windows. Staff were aware of these and followed plans to reduce the risk of these being used. The ward was for male patients only, and patients shared bathroom facilities.

The ward had a dedicated quiet room, which patients could use, and staff could use these rooms for de-escalation if needed to prevent incidents of violence and aggression.

All members of staff carried a personal alarm, and there were wall-based alarms throughout the ward as well as in patient bedrooms. When the ward had a member of staff who formed part of the response team for that day, an extra member of staff was scheduled on duty. The trust undertook weekly fire alarm tests and fire drills took place six-monthly.

Staffing levels (for registered and non-registered nurses) at the time of the inspection were a minimum of 3 during the day, and 4 at night. The provider carried out 6-monthly safer staffing reviews using the Mental Health Optimal Staffing Tool. Prior to the inspection the trust had increased staffing at night to 4 staff members. Staff told us that it was sometimes hard to manage risk and patient support during the day, particularly at weekends when there were fewer members of the multidisciplinary team available to assist. Senior managers advised that following the inspection, they had added an extra staff member shift at weekends. Daily safer staffing huddles were held including ward and senior managers on weekdays. Weekend staffing was discussed on Friday with mitigations put in place where needed. The trust noted that incidents were no more frequent at weekends than weekdays. At the time of the inspection there were 12% vacancies on the ward, with a registered nurse and a non-registered nurse position being recruited to. Staff noted the importance of having the right balance of male and female staff on shift to ensure the safety of the ward.

Staff knew patients well and said that they were supported by their colleagues and managers. A student nurse was particularly positive about their induction training and the organisation on the ward. When temporary nursing staff were used, those staff received an induction to familiarise them with the ward and policies. The temporary staff completed a checklist to demonstrate they had been inducted to the ward. No agency staff were working on the ward. We observed an effective staff handover meeting.

There was no occupational therapist in post at the time of the inspection, but the post had been recruited to due to start in January 2025. Staff told us that there was adequate medical cover to meet the needs of patients. A duty doctor and an on-call consultant were available out of hours.

Most staff had received and were up to date with their mandatory and statutory training courses as at the time of the inspection. Overall compliance with mandatory training on the ward was at 95.7%. 78% of staff had completed immediate life support training, 83% had completed basic life support training, and 33% had completed fire warden training at the time of the inspection.

Staff also completed specialist training in trauma informed approach, Oliver McGowan training, dialectical behavioural therapy, HCR-20 assessment, and re-motivation. Some but not all staff had training in working with patients on the sex offenders register, Multi-Agency Public Protection Arrangements, and in substance misuse.

Staff on the ward completed competencies in particular areas. At the time of the inspection 88% of staff had completed competencies in seclusion, 94% in search and security, and 94% in engagement and observation.

At the time of the inspection one staff member had recently returned from long term sickness, and another staff member remained on long term sickness.

The ward environment was visibly clean and well maintained. Relevant health and safety environmental checks were in place across the ward. Staff and patients said that the level of cleanliness on the ward was good.

Staff used a yellow plastic bin to dispose of needles and sharps. The yellow bins in the treatment rooms were dated on opening, and not over-filled.

Staff adhered to infection control principles, including handwashing and wearing appropriate personal protective equipment such as disposable gloves.

Staff completed monthly infection control, hygiene assessment, decontamination of equipment, and hand hygiene audits.

Staff ordered, stored, dispensed and disposed of medicines safely. Medicines were stored at the correct temperatures to remain effective. Staff monitored the fridge and room temperature where medicines were stored daily. The medicines fridge was not hard wired to prevent accidentally being switched off. We raised this with staff who said that they would put up a notice to warn staff not to switch off the fridge.

Controlled drugs were stored and managed appropriately. Members of the pharmacy team visited the wards and checked patient prescriptions.

We reviewed the medicine administration records. These were completed appropriately. Staff signed when they administered medicines or recorded why not, in accordance with trust policy. Staff noted allergies and potential adverse reactions on the patients’ records. The prescriber gave staff clear directions about when they should administer ‘as required’ medicines.

Staff completed audits of prescription charts, clinical rooms and physical health each month. Patients prescribed medicines (such as clozapine) where levels could be affected by smoking, were given smoking diaries, and had plasma levels checked to ensure medicine levels were within range.