Norfolk and Suffolk NHS Foundation Trust

Updated 22 October 2025

Norfolk and Suffolk NHS Foundation Trust (NSFT) was formed on 1 January 2012 following a merger of Norfolk and Waveney NHS Foundation Trust and Suffolk Mental Health Partnership Trust. The Trust supports a population of around 1.6 million people and employs over 5000 staff. NSFT delivers specialist mental health services for children, adults, people with a learning disability and autistic people across a variety of inpatient, community and primary care settings. Teams work in geographic care groups with dedicated local clinical leadership teams across the following areas:

• West and south Norfolk
• North Norfolk and Norwich
• Great Yarmouth and Waveney
• West Suffolk
• East Suffolk

The main sites are at Hellesdon Hospital Norwich, Wedgwood House Bury St Edmunds and Woodlands Unit in Ipswich but staff are based in more than 50locations.

NSFT is part of 2 local integrated care systems (ICS), Norfolk and Waveney ICS and Suffolk and North East Essex ICS. In February 2025 NHS England confirmed that NSFT had been moved from NHS oversight framework segment 4 (mandated national intensive support) to segment 3 (mandated regional support and oversight). In line with this NSFT was removed from the Recovery Support Programme (RSP), formerly known as “special measures”.

In June 2025 the new NHS Oversight Framework 2025/26 was published. The new framework describes a consistent and transparent approach to assessing NHS trusts, ensuring public accountability for performance and providing a foundation for how NHS England works with systems and providers to support improvement. NHS England will use the performance assessment process to measure delivery against an agreed set of metrics. This will determine the segment score for each provider and identify where improvement is required. Providers are allocated a segment between 1 and 5, with organisations in segment 1 considered to be consistently high performing across all domains and those in segment 5 being the most challenged and lowest performing. Segmentation was published in September 2025 placing the trust in segment 4.

We undertook a trust level (well-led) assessment of the trust which included an onsite visit on 13-15 May 2025. We also held 18 staff focus groups on and off site and observed board and committee meetings between April and May 2025.We assessed all 8 of the quality statements in the well-led key question in this assessment.

The well-led review followed assessments of 2 of the trusts frontline service groups (assessment service groups - ASGs): community mental health services for adults and crisis services and health based places of safety. These assessments were completed as part of the CQC's Adult Community Mental Health Programme. This programme of inspections contributes to CQC's commitment to inspect the standard of care in community mental health services across the country. These assessments also took into account information of concern we had previously received about community services at the trust.

The assessments identified concerns that community teams did not always ensure medicines and treatments were safe and met people’s needs capacities and preferences and that people were not always involved in planning. . Within crisis services there were also concerns relating to the deployment of sufficient staff and assessing emergency referrals as well as access to outside space at one of the trust’s health based places of safety. However, significant improvements were also noted across both ASG’s compared to previous inspections, including around physical health needs, data and governance, mandatory training and telephone access to crisis services.

We identified areas for improvement across all 8 well-led quality statements. These areas were as follows:

• Whilst there had been an improvement in culture overall, there continued to be pockets of poor culture across the organisation and staff continued to report poor experiences of working at the trust. Ongoing workstreams need to be monitored to ensure there is continued and sustained improvement in culture and experiences of staff across the trust.
• Many staff we spoke with reported that senior leaders were not visible. Ongoing work needs to be done to ensure the programme of regular service visits results in greater visibility to staff working across the organisation.
• There wasn’t always a positive working relationship between the trust and its governors. Work was needed to ensure all governors felt confident and empowered to fulfil their roles.
• The trust had been through a period of prolonged instability within the executive leadership team. The board was now stable, but this stability needs to be maintained to continue to rebuild relationships and confidence in the trust both internally and externally.
• Some staff we spoke with still didn’t feel safe speaking up or confident that their concerns would be actioned. The trust must continue to rebuild confidence with staff, ensure freedom to speak up processes are effective and be able to clearly demonstrate it has acted on concerns.
• Further work needs to be done at the trust to understand the full impact and implications of ongoing issues relating to staff skills mix. The lack of reporting and escalation of this issue prior to its identification also needs to be understood.
• Staff continued to raise concerns about racial and disability discrimination at work and the trust’s commissioned workforce race equality report highlighted significant concerns around the experiences of Black, Asian and ethnic minority staff at the trust. The trust must ensure the recommendations from this report are prioritised and actioned to ensure significant improvements are seen and sustained.
• Mental Health Act data highlighted concerns surrounding ethnic minority over representation especially in relation to section 136 and the criminal justice pathway. Work must be done to understand the reasons for this and to take action to improve the experiences of patients from an ethnic minority.
• There was further work that needed to be done to understand and address health inequalities across the trust’s services. This had been identified by leadership at the trust who had started to implement positive changes
• There was limited medicines support available for community teams across the trust. Whilst there is an improvement plan in place, the trust needs to ensure this is effectively implemented.
• Responding to complaints was taking longer than the stated timescales. The trust was taking action, but the success of these interventions needed to be monitored to ensure it was sustained.
• PSIRF (Patient Safety Incident Response Framework) had been implemented at the trust, however we saw significant delays in completing patient safety investigations. The trust was aware of this and had an action plan in place, but the trust must ensure the necessary changes are made to reduce the timeframes for these investigations. The trust had also identified learning from these investigations as a priority and must continue to implement measures that drive changes in practice.

However, we also recognised significant positive change across the organisation and there were also positive findings across all quality statements. These were:

• Across our ASG assessments and this well led assessment it was been evident that there were passionate, hardworking staff who were very committed to the trust and the people they served. Staff also told us they felt services were improving.
• Recent substantive appointments to the board had given stability and brought experience from high performing organisations.
• There was greater visibility of local leadership and groups such as allied health professionals (AHP) had professional leadership in place. All leaders were supported with development opportunities.
• There had been a marked improvement in stakeholder relationships.
• The new governance structure provided a robust framework and there was a clear and improved line of site between ward and board. The creation of strategic clinical collaboratives will also ensure staff teams from across localities remain connected and encourage best practice.
• There was strong clinical leadership and prioritisation at board level and locality leadership structures also promoted clinical voice.
• There was integrated reporting system to ensure all deaths were appropriately recorded. This gave a robust foundation to ensure the trust could learn from deaths moving forwards.
• Co-production with people who use services and carers had been prioritised by the trust and we saw clear examples where lived experience had impacted positive change in services.
• The sustainability lead was passionate and showed innovative working that not only promoted sustainability but also a connection to the organisation’s purpose as a mental health trust. It was also clear the board was engaged with and promoting the sustainability agenda.
• The trust was working to address issues in relation to speaking up, including an opportunity to write directly to the chief executive. This route had seen early success, including a high proportion of staff using their own name when reporting, rather than highlighting concerns anonymously.

Updated 21 January 2025

We carried out an inspection of the community mental health services for adults of working age on 18, 19 and 20 March 2025. This inspection was completed as part of the CQC's Adult Community Mental Health Programme. We also inspected mental health crisis services and health-based places of safety. The programme of inspections contributes to CQC's commitment to inspect the standard of care in community mental health services across the country. We undertook a short notice announced, comprehensive inspection of this service, looking at all 5 key questions to assess if services were safe, effective, caring, responsive and well led.

The trust has community mental health services across Suffolk and Norfolk.

The inspection team comprised of 4 CQC inspectors, 1 CQC senior specialist in mental health, 3 CQC pharmacist specialists (also referred to as medicines inspectors), 2 specialist advisors, and 1 Expert by Experience (people who have experience of using, or caring for someone who uses, services).

In Norfolk and Suffolk, we inspected 6 community mental health teams. These were the community mental health teams (CMHTs) West Norfolk in Kings Lynn, Great Yarmouth and Waveney in Great Yarmouth, Coastal Suffolk in Ipswich and Bury South in Bury St Edmunds. These teams support working age and older adults who need a specialist mental health service. Staff in the Suffolk teams told us that the team names were changing from Integrated Delivery Teams to CMHTs. We also visited the Early Intervention in Psychosis Services (EIS) East Suffolk base at Wickham Market and Great Yarmouth and Waveney. The EIS team support people between the ages of 14-65 who are experiencing symptoms of a first episode of psychosis. We also spoke with staff working in the Young People’s Mental Health teams at Ipswich and Bury St Edmunds. These teams support younger people aged 14-25 who require specialist mental health treatment. Referrals to the CMHTs were processed by the Access and Assessment team. Referrals to the EIS and Young People’s Mental Health teams were triaged by the receiving team.

For our inspection, we looked specifically at the services provided to adults from 18 to 65 years old, in line with how we register assessment service groups.

The trust’s community mental health services are spread across Suffolk and Norfolk

Community Mental Health teams

• West Norfolk
• East Norfolk
• Central Norfolk City
• East Suffolk Ipswich
• East Suffolk Coastal
• Central Suffolk
• Bury St Edmunds North
• Bury St Edmunds South
• Great Yarmouth and Waveney

Early intervention teams

• West Norfolk
• West Suffolk
• Norfolk and Waveney

We spoke with 44 staff of various grades and roles. We spoke with 18 people who use services and 9 carers. We reviewed 21 care records for people who use services and observed a range of meetings and appointments including care and treatment being delivered. We reviewed a range of data including complaints, incidents and policies. We reviewed feedback and data from Norfolk Healthwatch.

We last inspected the service as part of an unannounced comprehensive inspection in November 2022 when we rated safe, responsive and well led as requires improvement and caring and effective as good, which led to this assessment group being rated overall as requires improvement. At our last inspection we found breaches in regulation relating to staff training, inconsistent recording of risk assessments, long waits for psychology and lack of contact whilst on waiting lists. We also found breaches relating to trust leadership forming partnerships with stakeholders to look at models of services to meet the needs of the population and data availability in a consistent format. The service had made improvements and is no longer in breach of previous regulations.

At this inspection we rated the service overall as good. We found a breach in relation to safe care and treatment. The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning. We have asked the provider for an action plan in response to the concerns found at this assessment.

Updated 21 January 2025

We carried out an inspection of the trust’s mental health crisis services and health-based places of safety on 18, 19 and 20 March 2025. This inspection was completed as part of the CQC's Adult Community Mental Health Programme. We also inspected community mental health services for adults of working age as part of the programme. The programme of inspections contributes to CQC's commitment to inspect the standard of care in community mental health services across the country. We undertook a short notice announced, comprehensive inspection of this service, looking at all 5 key questions to assess if services are safe, effective, caring, responsive and well led.

The trust has 5 Crisis Resolution and Home Treatment (CRHT) teams, 3 in Norfolk and 2 in Suffolk. It has 5 health-based places of safety (HBPoS) at Kings Lynn, Bury St Edmunds, Ipswich, Great Yarmouth and Norwich.

The inspection team comprised 1 CQC inspector, 1 CQC analyst, 1 CQC clinical fellow, 2 CQC senior specialist in mental health, 3 CQC pharmacist specialists (also referred to as medicines inspectors), 1 Mental Health Act reviewer, 2 specialist advisors, and 1 Experts by Experience (people who have experience of using, or caring for someone who uses services).

During the inspection we:

• visited the CRHT teams at Great Yarmouth and Waveney, Central Norfolk and East Suffolk.
• visited the HBPoS at Northgate Hospital, Great Yarmouth, Hellesdon Hospital, Norwich and Woodlands Unit, Ipswich.
• visited the 24-hour urgent mental health telephone helpline (111 service) in Norfolk.
• spoke with 40 staff of various all grades and roles, including 8 staff on duty at the HBPoS.
• spoke with 17 people who used services and 11 carers
• observed care and treatment in the health-based places of safety and Woodlands Unit.
• reviewed 19 care records for people who used services, including medicines administration and associated care records.
• reviewed an additional 66 records of patients who were currently or recently subject to section 136 of the Mental Health Act

We last inspected the service in September 2022 when we rated safe, responsive, effective and well-led as requires improvement and caring as good. This led to the assessment service group being rated overall as requires improvement. At our last inspection we found breaches in regulation relating to physical health assessments, access to teams out of hours, accurate data for crisis services to support monitoring of services, sufficient staffing to meet the 4-hour target for emergency referrals and mandatory training.

At this inspection we rated the service as requires improvement. We found 3 breaches of regulation relating to timeliness of emergency referrals, access to outside space at the Woodlands Unit health-based place of safety and staffing. The HBPoS at Woodlands Unit did not allow people who used services direct access to outside space and fresh air, which is not in line with the Mental Health Act code of practice, though the service was taking action to address this. The service still did not always deploy sufficient staff in all areas, due to high numbers of vacancies in some teams, though the service was taking action to address this. The service still did not always assess emergency referrals within 4-hours in line with national standards. We have asked the provider for an action plan in response to the concerns found at this assessment.

However, the service had made some improvements and was no longer in breach of regulations relating to assessing and responding to people who used services physical health needs, data and governance, mandatory training of staff and telephone access to crisis services. The service now ensured people who used services received a physical health check and physical health needs were reflected in care plans. Managers and leaders had access to accurate data to appropriately monitor the effectiveness of services. The service now had a 24-hour urgent mental health helpline (111 service) for professionals and the general public and people who used services to access crisis services.

Updated 24 February 2023

Updated 28 April 2022

Updated 15 January 2020

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

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.

Updated 28 April 2022

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.

However:

• 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.

Updated 24 February 2023

Updated 24 February 2023

Updated 24 February 2023