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Chief Inspector of Hospitals recommends Norfolk and Suffolk NHS Foundation Trust remains in special measures

28 November 2018
Norfolk and Suffolk NHS Foundation Trust
  • Media,
  • Mental health hospital services

England's Chief Inspector of Hospitals has recommended Norfolk and Suffolk NHS Foundation Trust remains in special measures following a Care Quality Commission inspection.

The trust was rated Inadequate overall and placed into special measures following an inspection in July 2017. On their return, between 3 and 27 September this year, inspectors found the trust had failed to make significant improvements. As a result CQC is recommending the trust remains in special measures.

CQC’s Deputy Chief Inspector of Hospitals (and lead for mental health), Dr Paul Lelliott, said: “On our return to Norfolk and Suffolk NHS Foundation Trust we found that insufficient improvements had been made and we still had significant concerns.

“At our inspection of 2017, we raised concerns about safety, culture and leadership and told the trust it must take urgent action to put things right. Some of these were issues that we first raised with the trust in 2014.  We were therefore very disappointed to find that some of these concerns have still not yet been fully addressed. “The trust leadership team has not taken action at the pace required to bring about sustained improvement and to resolve failings in safety. The people who depend on this trust for care and support deserve better.

“Some of the buildings in which wards and community teams are based did not provide a safe environment for patient care and staff did not assess and manage the risks they pose to patients in a consistent way.  Staff did not manage medicines and equipment safely, they did not undertake proper reviews of patients who were in seclusion and there were insufficient staff to meet patients’ needs in some community services. CQC has raised all of these issues during previous inspections.

“We were particularly concerned about the safety of patients waiting for assessment or treatment by the community mental health teams. Not all services were meeting their targets for assessment and the trust did not respond appropriately to emergency or urgent referrals. Inspectors found that staff were sometimes ‘downgrading’ referrals from urgent to routine without ensuring that it was safe to do so. There were instances of people who had significant needs being denied a service and records showed some patients harmed themselves while waiting for contact from clinical staff.

“Managers have not ensured that when things go wrong, they learn and share lessons to reduce the likelihood of the same thing happening again.

“The trust leadership must take robust action now to ensure that improvements are made. We have called upon NHS Improvement to offer support to the trust to make the immediate changes necessary to keep patients safe. We will continue to monitor the trust closely and this will include further inspections.”

The trust has been told it must make the following improvements:

  • The trust must assess, monitor and improve the quality and safety of services to ensure actions from the CQC’s inspections in 2014, 2016 and 2017 are completed.
  • The trust must ensure risks to the health and safety of patients are mitigated; this includes the continuation of work to reduce the risk of ligature points.
  • The trust must ensure that medicines and equipment are managed safely.
  • Staff must ensure that they protect patients’ privacy and dignity during periods of seclusion and segregation.
  • Sufficient numbers of suitably qualified and experienced staff must be available to meet people’s care and treatment needs.
  • Managers must ensure that learning from serious incidents is shared and any actions implemented.
  • All patients must be allocated a care coordinator and provided with timely access to services or treatment.
  • The trust must ensure all teams comply with the four-hour emergency assessment target for referral to assessment.

Despite the seriousness of our concerns, our inspectors also found isolated examples of outstanding practice at the trust. These included:

  • On the child and adolescent mental health wards staff gave their free time to benefit patients and were passionate about making a difference, services were tailored to meet young people’s individual needs and a wide range of therapeutic activities were offered into the evenings and at weekends.
  • The manager at Mariner House adult learning disability team held weekly multidisciplinary meetings with the social community care team and GP liaison nurses to discuss patients and improve inter-agency team working. This improved patient access to the right support more quickly.

Norfolk and Suffolk NHS Foundation Trust is rated Inadequate overall, Inadequate for whether services are safe, responsive and well-led, Requires Improvement for whether services are effective and Good for whether services are caring. The rating for whether services are responsive at CQC’s previous inspection was Requires Improvement.


For further information please contact regional engagement manager, Louise Grifferty, on 07717 422917.

CQC’s press office is available on 020 7448 9401, during office hours, or, out of hours, on 07789 876508. For general enquiries, call 03000 61 61 61.

Last updated:
29 November 2018

Notes to editors

The Chief Inspector of Hospitals, Ted Baker, leads inspection teams which are headed up by clinical and other experts including trained members of the public. Whenever CQC inspects it will always ask the following five questions of every service: Is it safe? Is it effective? Is it caring? Is it responsive to people’s needs? Is it well-led?

This report describes our judgement of the overall quality of care provided by this trust. It is based on a combination of what we found when we inspected, information from our ‘Intelligent Monitoring’ system, and information given to us from patients, the public and other organisations

The Care Quality Commission has already presented its findings to a local Quality Summit, including NHS commissioners, providers, regulators and other public bodies. The purpose of the Quality Summit is to develop a plan of action and recommendations based on the inspection team’s findings.

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.