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Norfolk and Suffolk NHS Foundation Trust

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Overall: Requires improvement read more about inspection ratings
Important: Services have been transferred to this provider from another provider

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Overall inspection

Requires improvement

Updated 24 February 2023

We inspected Norfolk and Suffolk NHS Foundation Trust because at our last inspection we rated the trust inadequate overall and took enforcement action.

We carried out an unannounced comprehensive inspection of 2 core services – child and adolescent mental health wards and community-based mental health services for adults of working age; and unannounced focussed inspections of 4 core services which were - acute wards for adults of working age and psychiatric intensive care units, long stay or rehabilitation mental health wards for working age adults, mental health crisis services and health-based places of safety and wards for older people with mental health problems. We also inspected the well-led key question for the trust overall.

We chose these 6 core services to see if they had complied with the warning notice we issued and if there had been improvements since our last inspection in November and December 2021.

The trust provides the following mental health services, which we did not inspect this time:

• Wards for people with a learning disability or autism.

• Specialist community mental health services for children and young people.

• Community based services for older people

• Forensic inpatient or secure wards

• Community mental health services for people with a learning disability or autism

Our rating of services ​improved​. We rated them as ​requires improvement​ because:

  • We rated safe, effective, responsive and well-led as requires improvement, and caring as good.
  • Three of the core services we inspected had improved. The child and adolescent mental health ward had improved from a rating of inadequate to a new rating of good. The acute wards for adults of a working age and the community-based mental health services for working age adults had both improved from a rating of inadequate to a new rating of requires improvement. One core service, mental health crisis services had remained requires improvement overall. The other 2 services, rehabilitation ward and wards for older people with mental health problems could not be rated as we only inspected a few of the key questions. Our overall rating took into account the current ratings of the 5 core services we did not inspect at this time.
  • Across the 6 core services we rated 24 domains associated with the key questions. Four domains had improved by 2 ratings from inadequate to good; 10 had improved by 1 rating; 9 had stayed the same and 1 had seen a reduction in the rating.
  • The most concerning ratings were the inadequate ratings for the safe domain for acute wards for adults of a working age and wards for older people with mental health problems. For these services we found that improvements required at the last inspection as stated in the warning notice had not been achieved consistently across the wards. For example, on a few wards ligature reduction work had not yet taken place (although was planned); some wards did not have enough staff who had completed the mandatory training; a few staff were not carrying out restrictive interventions appropriately such as restraint or seclusion. There were still a small number of wards where standards of care needed to significantly improve. This demonstrated that the positive changes focusing on patient safety introduced at pace by the trust since the last inspection needed some further refinement and embedding to improve the consistency of care. The trust recognised that there were still challenges, but the Care Quality Commission had confidence that the trust had leaders with the commitment and experience to continue to take this forward at pace as demonstrated by services with improved ratings.
  • Whilst the rating of the trust had improved the Care Quality Commission chief inspector of hospitals has recommended to NHS England and NHS Improvement that the trust remains in the Recovery Support Programme at the current level to ensure it receives ongoing relevant support to continue to make the changes required.

Our inspection identified the following areas where further improvement was needed:

  • The trust had access to a wide range of data including staffing, incidents, complaints, safeguarding, whistleblowing, feedback from quality and safety review visits but this was not always brought together effectively. This meant that services which were struggling might not be identified at an early stage to ensure they had the necessary ‘wrap around’ support package to improve in a timely manner.
  • There are examples of where essential environmental improvements had not happened fast enough to address patient safety concerns and whilst systems were in place to request this work, further input was needed to ensure repairs took place in a timely manner.
  • We observed a range of ability and confidence in ward and team managers and in middle management in the care groups. Managers were not always escalating concerns quickly enough to get the help they needed. The services where we had the most concerns on this inspection were also where managers appeared to lack experience or motivation. Whilst the trust had leadership development opportunities in place both for groups and individuals, these needed to be further developed to support people to perform to a consistently high standard. The trust had secured funding to increase their leadership development team with plans to develop a talent management programme, but this had not yet come into effect.
  • Clinical leadership needed to develop and embed further. For nurses there was a well-developed nurse leadership structure reflecting the geography of the trust and the patient safety priorities for the chief nurse. Allied health professionals were line managed by the chief nurse. Each care group was led by a clinical director (mostly medics), a lead nurse, a service director and people participation lead. Despite these leadership roles the consultant psychiatrists did not feel they were fully engaged in decision making relating to the trust and there was an acknowledgement that this could improve. The chief medical officer planned to actively involve the medics in looking at future models of care which was welcomed by the consultant psychiatrists. He was developing plans to improve their leadership development. He was also reviewing the engagement of junior doctors. It was also acknowledged by the trust that the psychologists should either be managed by the chief medical officer or chief nurse rather than the current arrangement of management by the deputy chief executive.
  • The trust had considerable further work to undertake in terms of their digital transformation. The current contract for the patient record system will expire in April 2025 and they were deciding which system would be best meet their needs going forward. This decision making was been operationally led by the chief operating officer. In the meantime, access to live data was limited to identify areas for improvement and inform managerial decision making. Some data was available through Power BI, but many staff did not have the skills to access and make use of this. However, at a trust wide level for key governance committees, data was felt to be largely accurate, well presented and appropriately analysed.

Our inspection identified a number of areas where improvements had taken place:

  • The trust was moving from a position of being reactive in response to external stakeholders including the Care Quality Commission to being proactive. There was a clear and realistic plan in place to deliver phased improvement. The inspection found evidence of the work being done to address the basics. There were many examples of this including mandatory training compliance at 90%, appraisal completion rates at 95%, improved systems and training for conducting therapeutic observations of patients and improvements to medicine management. The Care Quality Commission inspection found an example of where a restraint had been carried out in an unacceptable manner, however systemic improvements were taking place which should reduce the likelihood of this happening in the future. This included the rolling out of accredited training for the prevention and management of violence and aggression where most staff had been trained or their training was booked and the strengthening of a trust wide team supporting wards to reduce the use of physical interventions and where needed ensure this is done appropriately.
  • Since the last inspection the executive leadership team had strengthened. The 3 appointments had come with considerable experience, the deputy chief executive and chief people officer, chief medical officer and chief operating officer. The executive leadership team had clear leadership roles for delivering the strategic priorities and were actively working on translating this into practice. For example, the chief operating officer was leading work to deliver timely access to services. This included ensuring there was an understanding of the reasons for waiting lists, improving the quality of the data, reviewing the models of services and reducing unwarranted variations between similar teams. Our inspections of adult community mental health teams found that whilst there were waiting lists, the people on them were being monitored and receiving access to some therapeutic input. The chief operating officer recognised the complexity of this work and the need to engage with external stakeholders such as NHSE and join programmes to learn from other providers.
  • Since the last inspection the governance processes had been strengthened. The number of sub-committees of the Board had been reduced to streamline the systems for gaining assurance. External stakeholders had become active participants in the governance processes through membership of committees. We found examples of where assurance processes had been strengthened. The trust had developed an evidence assurance group to ensure the data being used to monitor progress with the Care Quality Commission action plan was accurate and corroborated to ensure the improvements were really happening in practice. The trust had strengthened a team which visited wards and teams to carry out quality and safety reviews. This team had carried out over 100 visits between March to October 2022 and these included patient representatives and external stakeholders. This had identified areas for improvement both for individual service. and trust wide. This had led to changes such as an improved staff induction process. The trust had just introduced a new method of completing clinical audits which were done online with the results submitted electronically. These audits reflected the areas identified at the last inspection where improvements were needed. The chief operating officer had strengthened assurance through the quality performance meetings where the care groups were held to account for the services they managed. These were now taking place monthly, made better use of data and set clearer expectations in terms of improvements. Finally, the number of visits of executives and non-executive directors to services had increased. Twenty-nine visits had taken place since late spring by the chair and non-executive directors to services. Following our inspection there was a recognition that assurance could be strengthened further – particularly the review of incidents through viewing CCTV. This had been taking place, but the quantity and quality of this review was being developed.
  • There was a full recognition by the trust of the need to improve the culture of the organisation. Many of the staff we met during the inspection talked about the improvements in the culture, but it was clear that there were still some teams where staff were experiencing discrimination and had poor morale. Since the last inspection work had taken place to start improving the culture although there was a recognition that it would take time to see significant changes in measures such as the staff survey results although the trust were hopeful of seeing a few green shoots. The trust leaders recognised the importance of role modelling the appropriate behaviours which was very evident throughout the well led review. They were clear of the need to avoid a blame culture and create one where staff felt supported to learn and improve. They had introduced a leadership and management behaviour framework. Executive leaders were holding weekly online ‘hear to listen’ events where any staff could join and ask any question anonymously if they wished. The calls were recorded for colleagues who could not join at the time and were being attended by 200-300 staff. The trust had launched a trust wide piece of work to listen to staff and turn this into action and about 30% of the trust staff had chosen to complete the initial survey. These results were available at the time of the inspection and were enabling the trust to start understanding the scale and nature of the issues. The process will support further work with teams to listen and promote improvements. The trust was working to improve opportunities for staff to speak up and had just started to use an external speak up guardian arrangement to ensure greater independence from the trust. The trust was supporting the staff networks, which each had an executive sponsor, and had been provided with extra resources to develop further.
  • The trust had recognised that it needed to bring forward the work to refresh the trust strategy to align with the plans in the wider health and social care economy across the 2 system geographies. The aim was to have a new strategy by April 2023 and use the ongoing staff engagement work to consult as needed. The refreshed strategy would be clinically led and clinically informed by the work which had been started by the chief medical officer to look at future models of care. There were plans to also refresh the workforce, estates and digital supporting strategies later in the year. At the time of the inspection the trust strategy was displayed across the services, was available on the intranet, used to align governance papers but not widely referred to by members of staff.
  • The trust was actively involved in the work across both care systems in Norfolk and Suffolk. The chief executive was a member of both Integrated Care Boards. The trust leaders understood that there needed to be effective system working to meet the mental health needs of the population. They also recognised that the focus should not be on growing the trust, but rather to identify the areas they could do well as a secondary healthcare provider and where other providers including those in the third sector were better placed to meet people’s needs. Since the last inspection there had been the addition of an Improvement Board as a sub-committee of the Board to support partner engagement and monitor trust progress. There were positive examples of collaborative working. This included mental health nurses working in primary care across both systems. In West Suffolk the trust was working with Mind to support people with long term mental health conditions. Mind were able to offer people up to 3 interventions a week such as help with accessing fitness activities to improve their overall health. The trust recognised that there was scope to significantly grow this collaborative working.
  • Patient participation had embedded further across the trust over the last year. There were 8 people participation leads aligned to the care groups and 8 people participation co-ordinators. People participation was embedded across the trust with people with lived experiences actively involved in governance committees, quality assurance work, staff recruitment and training, research and quality improvement work. The trust also employed peer support workers across a range of services.

How we carried out the inspection

Before the inspection visit, we reviewed information that we held about each of the core services.

During the inspection visits, we:

  • Visited 19 wards and 12 teams
  • Spoke to 139 staff performing a wide range of roles
  • Spoke to 96 patients and 24 relatives or carers
  • Looked at 135 individual patient records
  • Looked at over 100 medication records
  • Attended 12 meetings including staff handovers, multidisciplinary meetings and patient community meetings
  • Looked at a number of records involved in the day to day operation of the services.

You can find further information about how we carry out our inspections on our website: www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

What people who use the service say

In the services we inspected, feedback from patients and carers was largely positive. On the child and adolescent mental health ward, patients said they felt safe and well cared for. Patients felt the staff were supportive of their needs and were friendly and approachable, staff had the skills to meet their needs and helped them through crisis and in difficult situations. Patients said the ward was calm and that there were enough staff to meet their needs and go out on activities and leave. On the acute wards for adults of working age and psychiatric intensive care units, patients were mostly happy with the care they received, thought there were enough staff to deliver care, felt safe on the wards and said that staff looked after their physical health. Patients told us they were involved in their care decisions. Overall patients thought that wards were clean and that they could give feedback about their care. On the long stay/rehabilitation mental health ward for working age adults, all patients said they felt safe on the ward and staff were kind, they felt listened to, and staff helped them when they needed it. On the wards for older people with mental health problems, patients told us they felt the staff treated them like human beings, and the atmosphere in the wards was relaxed and safe. Patients told us staff were always around and getting staff attention wasn't a problem. They felt involved in their care planning and decision-making and were able to be supported by their family members in the care planning process. Patients told us they were able to go to their weekly ward round to ask questions about their care.

In the community-based mental health services for adults of working age, most service users and carers we spoke to were very positive about the service. They told us staff were good at communicating with them and had a caring approach. All patient felt listened to, and said they were fully involved in their care. Feedback from carers was positive about the care and treatment family members received. Relatives told us that staff were supportive and they kept them involved in their loved one’s care. In the mental health crisis services and health-based places of safety, most patients and carers we spoke with said they were seen within the timeframe the staff told them when they initially called them, and they were seen regularly, which changed frequency dependant on their level of need. All patients and carers we spoke with told us patients received their medicines on time.

There were however some areas for improvement identified by people who used the service. On the acute wards for adults of working age and psychiatric intensive care units, 2 patients gave us examples where staff had not always been kind and polite and a further 4 said night staff were not always responsive to them, 1 patient had specific concerns about their care which we followed up with ward staff. Several patients told us they did not have a copy of their care plan or had not been given enough information about the medicines they were prescribed or the about ward when they were first admitted. In the mental health crisis services and health-based places of safety, 3 patients said they had no care plan and were not given a copy. Four carers said their relative had no care plan and 5 carers said they had not been given a copy. One patient told us they had no advice regarding their medicines.

Community mental health services with learning disabilities or autism


Updated 15 January 2020

The summary for this service appears in the Overall Summary of this report.

Community-based mental health services for older people


Updated 15 January 2020

Our rating of this service improved. We rated it as good because:

The summary for this service appears in the Overall Summary of this report.

Forensic inpatient or secure wards


Updated 28 November 2018

Our rating of this service stayed the same. We rated it as good because:

  • Managers had completed detailed ligature audits and management plans. The trust had carried out work to reduce ligature risks on the wards.
  • Staff had completed detailed, holistic and person-centred care plans and risk assessments in patient records reviewed. Staff completed full physical health checks for patients on admission and patients had care plans to meet physical health needs.
  • Staff treated patients with kindness and respect. Patients told us that staff were very nice, helpful, open minded and friendly. We observed caring interactions between staff and patients. Staff involved patients in their care plans and risk assessments. Patients could give feedback on the service and their treatment and staff supported them to do this. Patients were involved in staff recruitment.
  • Staff supported patients to meet their goals, and made sure patients had access to opportunities for education and work. Examples included a patient completing a business degree and another working as a volunteer in a café. Patients had access to a recovery college and to light industry workshops on and off site. Staff supported patients to access activities in the community, including sailing, rambling and dog walking.
  • Managers of the service provided strong, local leadership. Managers used dashboard information to monitor and improve the performance of their teams. Team morale was positive. Managers ensured staff were supported in their roles through supervision, team meetings, reflective practice sessions and training.


  • The trust had not ensured robust recording and learning from serious incidents. The trust had not shared learning from a patient death in 2014. There was a patient death in the forensic service in 2017. Both patients died after using the same style of ensuite door as a ligature anchor point. The trust were planning to pilot anti-ligature ensuite doors in new bathrooms but were not replacing existing ensuite doors. Staff had not recorded a serious incident that had occurred on Whitlingham ward in the patient’s progress notes. Details of the incident were not handed over to the next shift. Staff had not updated the patient’s risk assessment.
  • Staff did not always manage medicines and equipment safely. We found out of date medicines and medical equipment on five out of six wards. We found staff had administered as required medicines above prescription limits on two wards and had not always completed medicine administration records on one ward. Staff did not ensure that wards were fully equipped with accessible resuscitation and emergency equipment. Staff were not checking emergency bags and resuscitation equipment in line with trust policy on five out of six wards.
  • Seclusion was not always managed well. The trust had not ensured the seclusion room on Yare ward was free from hazards. Staff did not always follow the Mental Health Act code of practice for patients in seclusion and long term segregation. Reviews and observations were not carried out as required and staff had not instigated seclusion processes for a patient secluded in the courtyard.