Chief Inspector of Hospitals recommends Norfolk and Suffolk NHS Foundation Trust is put back into special measures

Published: 13 October 2017 Page last updated: 3 November 2022

England's Chief Inspector of Hospitals has recommended Norfolk and Suffolk NHS Foundation Trust is placed in to special measures for a second time following a Care Quality Commission inspection.

The trust was rated Inadequate overall and placed into special measures following an inspection in October 2014, but it had made sufficient improvements to exit special measures when inspectors returned last year.

During CQC’s visit in July this year, however, inspectors found the trust had not maintained standards and significant improvements were required. The trust is now rated as Inadequate.

CQC’s Chief Inspector of Hospitals, Ted Baker, said: “It is extremely disappointing that, on our return to Norfolk and Suffolk NHS Foundation Trust we found the board had failed to address a number of serious concerns; some of which we first reported on in 2014.

“When we inspected the trust for a second time in July 2016, we found sufficient improvement for us to recommend that the trust should exit special measures.  However, the trust did not continue this journey of improvement and, following our most recent inspection, we have once again rated the service as inadequate for safe and well led

“The trust board had not taken the action required to ensure that all its wards were safe environments for patient care, that clinical teams had a sufficient number of staff or that staff assessed and managed risk adequately.

“People did not always receive the right care at the right time due to a shortage of beds and sometimes people had been moved, discharged early or managed within an inappropriate service.

“Our concerns were compounded by the fact that the trust board did not have the information it needed to assure itself that the care provided was safe or of a good quality.  Without this information, we were not assured that the board would be able to take the action necessary to improve services. This is why I am recommending the trust is placed in to special measures and receives further support to enable it to improve, and ensure any improvements are embedded and sustained.

“The trust leadership, including the new interim chief executive, must ensure it takes robust action to ensure improvements are made and we will continue to monitor the trust closely. This will include further inspections.”

The areas where the trust has been told it must make improvements include:

  • The trust must ensure action is taken to remove ligature anchor points and to mitigate risks where there are poor lines of sight.
  • Seclusion and restraint must be managed within the safeguards of national guidance and the Mental Health Act Code of Practice.
  • Sufficient numbers of staff must be available at all times to provide care to meet patients’ needs.
  • The trust must ensure all relevant staff have completed statutory, mandatory and, where relevant, specialist training, particularly in suicide prevention and life support.
  • All risk assessments, crisis plans and care plans must be in place, updated consistently and reflect the full and meaningful involvement of patients.
  • People must receive the right care at the right time through suitable placements that meet their needs, give them access to 24 hour crisis services and ensure that discharge arrangements are effective.
  • The trust must ensure there are clear targets for assessment, that targets for waiting times are met and that people have an allocated care co-ordinator.
  • The trust must ensure that it fully addresses all areas of previous breach of regulation
  • Data about what is happening at the trust must be turned into performance information and used to inform practices and policies that bring about improvement and ensure that lessons are learned

Inspectors also found examples of good practice at the trust, which included:

  • At the Dragonfly unit we saw sensitive handling of difficult issues. Staff understood individual needs of patients. We saw staff show exceptional care and respect for a patient who was distressed.
  • The peer support worker role was embedded into community teams and a new ‘peer support navigator’ role was being trialled in adult community teams. This offered patients up to six sessions with the staff member to prepare for discharge and help reintegrate them back into their local community.
  • The trust had continued to develop ‘The Compass’ centre which provided a therapeutic education service for young people who might otherwise be placed in schools out of area. The compass centre was a partnership between Norfolk County Council children’s services and Norfolk and Suffolk NHS Foundation Trust.

Norfolk and Suffolk NHS Foundation Trust is rated ‘Inadequate’ overall, ‘Inadequate’ for whether services are safe and well-led, ‘Requires Improvement’ for whether services are effective, responsive and ‘Good’ for whether services are caring.


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About the Care Quality Commission

The Care Quality Commission (CQC) is the independent regulator of health and social care in England.

We make sure health and social care services provide people with safe, effective, compassionate, high-quality care and we encourage care services to improve.

We monitor, inspect and regulate services to make sure they meet fundamental standards of quality and safety and we publish what we find to help people choose care.