South London and Maudsley NHS Foundation Trust (SLaM) has outlined a comprehensive action plan to address areas for improvement identified in a Care Quality Commission (CQC) inspection. The inspection, which took place between June and October 2025, covered forensic, community mental health, crisis services, inpatient wards, and leadership.

While forensic services were rated Good, community, crisis, and acute inpatient services, along with the Well-Led domain, were rated as Requires Improvement. Key themes identified by the CQC included issues with seclusion documentation, enhanced care observations, care plans, emergency alarms, privacy and dignity, risk assessments, mandatory training compliance, restraint documentation, medication administration, physical health monitoring, waiting times, Mental Health Act assessments, supervision, community estates, and access to fresh air at the Health Based Place of Safety.

Illustration depicting a magnifying glass over a document labeled 'Mental Health Act', symbolizing scrutiny and review.
Illustration depicting a magnifying glass over a document labeled 'Mental Health Act', symbolizing scrutiny and review.

In response, SLaM has developed a detailed plan focusing on enhancing clinical quality, patient safety, governance, and organisational culture. Specific initiatives include implementing a swing bed model at the Health Based Place of Safety, improving reporting of Mental Health Act breaches, and developing a garden at the facility.

For community adult services, improvements are being made to care plans and risk assessments through the rollout of Dialog and Dialog Plus, alongside new community zoning protocols.

In acute adult inpatient services, observation processes are being enhanced, safeguarding training compliance is being improved, and a new audit system, AMaT, is being rolled out. The Trust has implemented improved observation processes and recording on acute adult inpatient services, along with a new enhanced care training competency. SLaM is also working on improving restraint technique compliance and reporting of Mental Health Act breaches.

A therapist listens to a patient during a counseling session.
A therapist listens to a patient during a counseling session.

The Well-Led inspection highlighted areas for improvement in governance, assurance, risk management, and organisational culture. To address this, SLaM has reviewed and updated its committee structures, including the Terms of Reference for all major oversight committees. A brand-new, senior-led Risk Oversight Committee has been established as a dedicated forum to track safety and operational risks across the Trust. The Trust has also rearranged its monthly meeting calendar to ensure oversight sub-committees meet after safety and performance reports are compiled, providing senior directors with dedicated time for thorough review.

SLaM has implemented initiatives to foster a listening culture, including dedicated slots at board meetings for staff and patients to share their experiences, and increased site visits by senior executives. A 24-hour independent Guardian Service has been established to allow staff to report concerns anonymously. This service is completely independent of the trust, allowing staff to report safety or discrimination concerns completely outside the internal chain of command. The Trust has also broken down reporting by local service lines to quickly spot and stop 'hotspots' of poor behaviour, bullying, or unfairness.

A woman in a suit and a man in scrubs smile while looking down at a document.
A woman in a suit and a man in scrubs smile while looking down at a document.

The Trust has also overhauled its safety investigations, retrained teams, and is involving clinicians in the design of the electronic patient record system.

The Healthier Communities Select Committee noted the report and requested a follow-up update in six to twelve months, which was agreed. The committee's proceedings can be found in the Public reports pack and the Agenda frontsheet. The minutes of the previous meeting are also available here.

An illustration depicting a community supported by hands, representing the
An illustration depicting a community supported by hands, representing the \"Healthier Communities\" theme.