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Provider: Norfolk and Suffolk NHS Foundation Trust Requires improvement

Read our previous reports on Norfolk and Suffolk NHS Foundation Trust, published on 3 and 6 February 2015.

Reports


Inspection carried out on 07 Oct to 06 Nov 2019

During a routine inspection

  • We rated well-led, responsive, effective and safe as requires improvement and caring as good. In rating the trust, we took into account the previous ratings of the three core services not inspected this time. We rated the trust overall for well-led as requires improvement. This was an improvement from the last inspection. Four of the trust’s 11 core services are now rated as good and five as requires improvement, one service was outstanding and one inadequate.
  • The trust board and senior leadership team were newly formed. At our inspection in 2018 we had significant concerns about the safety, culture and leadership of the trust. Since then, there had been a change in leadership. At this inspection, we found that, although some of the concerns had not fully been addressed, there had been a shift in approach and foundations had been laid to improve the direction of travel. We saw early improvements in almost all areas, but there had not been enough time to judge if these changes would be sustained. For instance, recent changes to the leadership structure had not yet embedded throughout the whole organisation and there were still a few key posts to be filled. We saw early improvement with the trust moving in the right direction, however, there was still much work to be done.
  • Our findings from key questions demonstrated that whilst governance processes had improved, they had not yet fully ensured that performance and risk were managed well. For instance, waiting lists remained high in the specialist children and young people community mental health teams. Staffing was also a concern within this core service. We saw risk assessments were not always updated within this core service.
  • The environment in the learning disability inpatient service was not safe or fit for purpose. The trust had made little attempt to remove or reduce the number of ligature points or improve lines of sight, nor was it a recovery focussed environment, as it did not encourage independence due to the number of risks within the environment. We had identified in the last inspection that not all wards were safe and fit for purpose.
  • Managers did not have effective oversight of medicines management nor checking of emergency equipment in six of the eight core services we inspected. Despite increased assurance work and an improved board assurance framework, medicines management issues we found had not been identified as a concern by the trust.
  • The trust missed opportunities to prevent or minimise harm. For instance, we found that the management of patients on enhanced observations was not always robust within the inpatient wards with gaps being found in some documents. This posed a direct risk to patient safety. Staff did not ensure patient records in all section 136 suites were completed or added to the system in a timely manner. This posed a risk to patient safety as if the patient accessed another service within the trust there would be no information or previous plan for staff to access and use when making clinical decisions. Staff did not consistently implement the smoke free policy. This led to patient frustration and increased the risk of fire setting.
  • We continued to see similar themes and recommendations (such as poor documentation in clinical records) from serious incident reviews which demonstrated learning was not always effective in improving practice. The trust recognised this and were proactively exploring ways to ensure learning took place across teams.
  • Some services had not yet embraced the cultural changes leaders were trying to develop. In one location in Suffolk, across four core services, we were concerned that some staff continued to report a lack of engagement with managers and pockets of low morale. We also saw evidence of bullying in one team in Norwich. The trust had sight of these issues and had acted, however action taken had not yet been sufficiently embedded to create wholesale change.
  • Some stakeholders did not feel that changes had truly positively impacted all patients, with feedback advising that some still did not feel listened to, with poor communication being a key feature of feedback from patients or their families. Equally, a lack of access to attention deficit hyperactivity disorder (ADHD) services and specialist children and adolescent community services (CAMH) was raised as a concern by stakeholders. We found that this aligned with our findings at this inspection.
  • The new governance and management structure were not yet fully implemented and embedded within the new care groups.  For example, the role of the people participation lead was new and not yet fully developed. Not all staff fully understood the roles and responsibilities of the leads. Leaders had not yet successfully provided all teams across the organisation with an understanding of how the new care groups worked. Some staff expressed concern that the organisational changes were too fast and lacked consultation.
  • Not all teams provided a range of treatment and care for patients based on national guidance and best practice. For instance, some community services had significant waiting times for psychological therapies. Teams lacked enough psychology staff to provide the range of care recommended by the National institute for Health and Care Excellence guidelines.

However:

  • Since the last inspection the trust had implemented a new quality strategy to include quality improvement (QI) as a core component within their strategic direction. The trust quality improvement plan (QIP) had been revised and was aligned to the new strategy. One hundred and eighty-seven staff had completed the three-day improvement leaders programme and were developing initiatives within local teams designed to improve care. Some of these initiatives had been identified as important by the local service users reflecting leaders increased focus on service user participation and co-production. We saw some of these initiatives within the local teams and noted increased efforts made to engage and listen to the service users voice. Staff across services told us that they were involved in the planning and delivery of their own service. This initiative was in the very early stages of implementation and had, therefore, not yet brought about the improvements that were envisaged.
  • The trust had a ‘putting people first’ strategy aimed at improving service user participation and to facilitate cultural change and de-centralise decisions. Concerns had been raised about organisational culture in the last four inspection reports, and the 2018 inspection report identified concerns that there was widespread low morale with staff feeling ‘done to’.  Following the 2018 inspection, the trust leadership team undertook (and continued to undertake) a range of engagement visits to services ensuring they were accessible to staff, although some staff reported that were unaware of visits to their services. At this inspection, more staff reported a sense of optimism and hope that real change was happening. More staff felt listened to, felt they could influence change, felt supported and had good working relationships with their managers.

  • The trust had improved its approach to learning from and managing serious incidents as a result of feedback from families and staff. Trust committees and the trust board had sight of incident data. The trust took proactive steps to address themes identified and improve ways to share learning across services. A new serious incident scrutiny panel and serious incident team had been created to report findings from investigations to the board. The trust recognised there was still work to be done to embed and improve this process further.
  • The trust collected reliable data and analysed it. This was a significant improvement from the last inspection. Staff across most services could find the data they needed, in easily accessible formats, to understand performance, make decisions and improvements. The information systems were integrated and secure. Staff submitted data or notifications to external organisations as required. New ways of monitoring and addressing waiting lists had been implemented with evidence that many lists had reduced. This meant leaders were able to understand what was happening in their organisation and act when needed.
  • The trust had participated in some national improvement and innovation projects and undertook a wide range of quality audits and research. The trust was involved in 65 approved research projects during 2018-19 with 1800 people recruited over the year. The trust was recognised as being in the top 15 highest mental health organisations nationally for research recruitment. The trust had undertaken a quality improvement programme, steered by the Royal College of Psychiatrists, to reduce the incidents of restrictive interventions and restraints as part of a national programme. This was a significant piece of work which continued to have impact. The programme involved the patient voice who shared their experiences with staff. This success has been recognised by the Royal College of Psychiatrists who are leading the national programme.


CQC inspections of services

Service reports published 22 October 2021
Inspection carried out on 02 September 2021 During an inspection of Acute wards for adults of working age and psychiatric intensive care units Download report PDF (opens in a new tab)
Service reports published 18 June 2021
Inspection carried out on 10 May on site and 13 May remote interviews During an inspection of Reference: not found
Inspection carried out on 10 May on site and 13 May remote interviews During an inspection of Acute wards for adults of working age and psychiatric intensive care units Download report PDF (opens in a new tab)
Service reports published 22 January 2021
Inspection carried out on 3 - 11 November 2020 During an inspection of Acute wards for adults of working age and psychiatric intensive care units Download report PDF (opens in a new tab)
Inspection carried out on 3-17 November 2020 During an inspection of Mental health crisis services and health-based places of safety Download report PDF (opens in a new tab)
Service reports published 1 May 2020
Inspection carried out on 24 - 25 February 2020 During an inspection of Specialist community mental health services for children and young people Download report PDF (opens in a new tab)
Inspection carried out on 24 - 25 February 2020 During an inspection of Acute wards for adults of working age and psychiatric intensive care units Download report PDF (opens in a new tab)
Service reports published 15 January 2020
Inspection carried out on 07 Oct to 06 Nov 2019 During an inspection of Mental health crisis services and health-based places of safety Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 07 Oct to 06 Nov 2019 During an inspection of Community-based mental health services for older people Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 07 Oct to 06 Nov 2019 During an inspection of Wards for older people with mental health problems Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 07 Oct to 06 Nov 2019 During an inspection of Acute wards for adults of working age and psychiatric intensive care units Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 07 Oct to 06 Nov 2019 During an inspection of Community mental health services with learning disabilities or autism Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 07 Oct to 06 Nov 2019 During an inspection of Community-based mental health services for adults of working age Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 07 Oct to 06 Nov 2019 During an inspection of Specialist community mental health services for children and young people Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 07 Oct to 06 Nov 2019 During an inspection of Wards for people with a learning disability or autism Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
See more service reports published 15 January 2020
Service reports published 2 July 2019
Inspection carried out on 30 April, 1 and 2 May 2019 During an inspection of Community-based mental health services for adults of working age Download report PDF (opens in a new tab)
Service reports published 27 June 2019
Inspection carried out on 30 April, 1 and 2 May 2019 During an inspection of Mental health crisis services and health-based places of safety Download report PDF (opens in a new tab)
Service reports published 20 May 2019
Inspection carried out on 3 April to 5 April 2019 During an inspection of Specialist community mental health services for children and young people Download report PDF (opens in a new tab)
Service reports published 28 November 2018
Inspection carried out on 03 to 27 September 2018 During an inspection of Community-based mental health services for older people Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 03 to 27 September 2018 During an inspection of Long stay or rehabilitation mental health wards for working age adults Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 03 to 27 September 2018 During an inspection of Wards for older people with mental health problems Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 03 to 27 September 2018 During an inspection of Child and adolescent mental health wards Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 03 to 27 September 2018 During an inspection of Forensic inpatient or secure wards Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 03 to 27 September 2018 During an inspection of Wards for people with a learning disability or autism Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 03 to 27 September 2018 During an inspection of Community-based mental health services for adults of working age Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 03 to 27 September 2018 During an inspection of Specialist community mental health services for children and young people Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 03 to 27 September 2018 During an inspection of Community mental health services with learning disabilities or autism Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 03 to 27 September 2018 During an inspection of Acute wards for adults of working age and psychiatric intensive care units Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 03 to 27 September 2018 During an inspection of Mental health crisis services and health-based places of safety Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
See more service reports published 28 November 2018
Service reports published 13 October 2017
Inspection carried out on 10-20 July 2017 During an inspection of Specialist community mental health services for children and young people Download report PDF (opens in a new tab)
Inspection carried out on 10-20 July 2017 During an inspection of Wards for older people with mental health problems Download report PDF (opens in a new tab)
Inspection carried out on 10 to 20 July 2017 During an inspection of Community mental health services with learning disabilities or autism Download report PDF (opens in a new tab)
Inspection carried out on 10 to 20 July 2017 During an inspection of Wards for people with a learning disability or autism Download report PDF (opens in a new tab)
Inspection carried out on 10 - 20 July 2017 During an inspection of Community-based mental health services for adults of working age Download report PDF (opens in a new tab)
Inspection carried out on 10 July - 20 July, and 26 July 2017 During an inspection of Long stay or rehabilitation mental health wards for working age adults Download report PDF (opens in a new tab)
Inspection carried out on 10 July 2017 – 20 July 2017 and 25 July 2017 During an inspection of Mental health crisis services and health-based places of safety Download report PDF (opens in a new tab)
Inspection carried out on 10-20 July 2017 During an inspection of Child and adolescent mental health wards Download report PDF (opens in a new tab)
Inspection carried out on 10 July 2017 - 20 July 2017 and 28 July2017 During an inspection of Forensic inpatient or secure wards Download report PDF (opens in a new tab)
Inspection carried out on 10 to 20, and 25 July 2017 During an inspection of Acute wards for adults of working age and psychiatric intensive care units Download report PDF (opens in a new tab)
Inspection carried out on 10 - 20 July 2017 During an inspection of Community-based mental health services for older people Download report PDF (opens in a new tab)
See more service reports published 13 October 2017
Service reports published 2 August 2017
Inspection carried out on 30 May 2017 During an inspection of Wards for older people with mental health problems Download report PDF (opens in a new tab)
Service reports published 14 October 2016
Inspection carried out on 12 to 22 July 2016 During an inspection of Wards for people with a learning disability or autism Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 12 to 22 July 2016 During an inspection of Wards for older people with mental health problems Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 12 - 22 July 2016 During an inspection of Community mental health services with learning disabilities or autism Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 12 July 2016 – 22 July 2016 During an inspection of Mental health crisis services and health-based places of safety Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 12 July to 22 July 2016 During an inspection of Acute wards for adults of working age and psychiatric intensive care units Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 12 July 2016 - 22 July 2016 During an inspection of Long stay or rehabilitation mental health wards for working age adults Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 12 July 2016 - 22 July 2016 During an inspection of Forensic inpatient or secure wards Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 12 - 22 July 2016 During an inspection of Specialist community mental health services for children and young people Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 12 - 22 July 2016 During an inspection of Community-based mental health services for older people Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 12 - 22 July 2016 During an inspection of Child and adolescent mental health wards Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 12 July 2016 to 22 July 2016 During an inspection of Community-based mental health services for adults of working age Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
See more service reports published 14 October 2016
Inspection carried out on 03 to 27 September 2018

During an inspection looking at part of the service

Our rating of the trust stayed the same. We rated it as inadequate because:

  • The trust board and senior leadership team were in transition and had not formed to deliver a service that provided high-quality sustainable care. At our inspection of 2017, we had significant concerns about the safety, culture and leadership at the trust. We told the trust that they must urgently address concerns and meet regulation. At this inspection, we found that some of our significant concerns, some that we had raised with the trust in 2014, had not yet been fully addressed. We found that the board had not driven effective change at a pace and with sufficient traction to bring about improvements needed to resolve the failings in safety and to bring about sustained improvement.
  • When we last inspected, we told the trust leadership that they did not demonstrate a safety narrative running through the organisation and that that they should ensure that learning was captured from incidents and concerns. At this inspection, we found that the safety culture has not yet fully developed. Managers did not ensure that learning from incidents was shared and embedded across the trust. Not all ward and community environments were safe. The quality of environmental risk assessments varied across services. Not all clinical risks were managed. Staff did not manage medicines and equipment in a safe way. Patients in seclusion did not always have access to the appropriate reviews of their treatment. Vacancies remained high particularly for nursing and medical staff. The trust had not ensured there were enough staff in some community services to meet the needs of patients. All of these issues had been raised with the trust during previous inspections.
  • We found widespread low morale across services. This was attributed to a “do unto” attitude staff felt came from senior management and directors.
  • The trust was attempting to take a systematic approach to governance but this had not fully succeeded in bringing about an improvement to the quality of services or ensured that these delivered a high standard of care. The trust had developed systems for identifying risks and was planning to eliminate or reduce them, but these were not yet effective in coping with both expected and unexpected risks. At this inspection we found that key risks that were considered closed or mitigated had not been fully addressed. In some cases, work undertaken had created new risks. These included ligature point management, care planning, access and waiting lists, staffing levels and seclusion practice and environments. It is concerning that the trust’s own assurance process had indicated more progress in some areas than we found at this inspection.
  • We were very concerned about access to services and the management of the many patients who are on waiting lists. Not all services were meeting their targets for assessment. We were not assured that the trust responded appropriately to emergency or urgent referrals. Too many referrals were handed off inappropriately or refused and downgraded from urgent to routine without due care. We found many instances of people who had significant needs who were denied a service. Records showed that some patients had harmed themselves while waiting for contact from clinical staff'. Bed management remained challenging particularly in acute services. The planning of patients’ discharges did not always contribute to people staying out of hospital.

However:

  • Staff treated patients with compassion and kindness. They respected patients’ privacy and dignity, and supported their individual needs. We observed positive interactions and saw staff responding to individual patient need. Staff usually involved patients and those close to them in decisions about their care and treatment.
  • The service provided mandatory training in key skills to all staff and made sure everyone completed it. Managers made sure they had staff with a range of skills needed to provide high quality care. They supported staff with appraisals, supervision, and opportunities to update and further develop their skills.
  • Staff assessed the mental health and physical health of patients on admission. Staff supported patients with their physical health and encouraged them to live healthier lives.
  • Access to the clinical information system had improved. Work was underway to improve the forms and assessment documents that staff needed to complete for patients.
  • The trust has committed to improving services by learning from when things went well and when they went wrong, and has begun to promote training, research and innovation. The trust had participated in some national improvement and innovation projects and undertook a wide range of quality audits and research.

Inspection carried out on 15 to 30 May 2018

During an inspection looking at part of the service

When aggregating ratings, our inspection teams follow a set of principles to ensure consistent decisions. The principles will normally apply but will be balanced by inspection teams using their discretion and professional judgement in the light of all of the available evidence.

We found the following issues that the trust needs to improve:

  • Patients did not benefit from safe services in all areas. The breaches of regulation identified at our previous inspections had not all been resolved. Also, the board needs to take further and more timely action to address additional areas of improvement.
  • Performance information and data had not yet facilitated effective learning or brought about improvement to practices in all areas. Work had been undertaken to better capture risks and a clearer governance structure had been put in place with clearer lines of accountability. However, further work is required to meet the recommendations of a recent governance review of the trust.
  • The trust had not ensured that all risk assessments and care plans were in place, updated consistently in line with changes to patients’ needs or risks, or reflected patients’ views on their care.
  • Staffing was not sufficient in community mental health teams. Patients across the trust had not all been allocated a care coordinator following assessment. We were concerned that the procedures that managers had put in place were not sufficient to mitigate this risk.
  • Patients were still not always secluded safely or within appropriate environments. Ward staff were not meeting the standard for recording and monitoring of patients in seclusion.

However, the trust had addressed some of concerns that we raised at the previous inspection:

  • The trust had ensured that alarms were available to staff and that staff had access to a defibrillator and life support training.
  • The trust had made appropriate arrangements to manage mixed sex accommodation.
  • Overall mandatory training and appraisal had rates exceeded the 75% compliance target.
  • Some progress had been made in relation to recruiting additional staff to the wards and crisis teams and staffing levels were sufficient at the time of our inspection.
  • Some seclusion rooms were now meeting standards.

Inspection carried out on 10 to 20 July, 25, 26 and 28 July 2017

During a routine inspection

This report describes our judgement of the quality of care provided by Norfolk and Suffolk NHS Foundation Trust. Where relevant we provide detail of each core service, location or area of service visited.

We rated Norfolk and Suffolk NHS Foundation Trust as inadequate overall because:

  • The board had failed to address all the serious concerns that had been reported to them since 2014. The breaches of regulation identified at our previous inspections had not been resolved. The board did not ensure that the services provided by the trust were safe. They had not taken action to ensure that unsafe environments were made safe and promoted the dignity of patients. They had not ensured that there were sufficient staff to meet patients’ needs safely. They had not ensured that unsafe seclusion and restrictive practices were minimised or eradicated. The trust was not safe, effective or responsive at all services. The board needed to take further and more timely action to address areas of improvement.
  • We had a lack of confidence that the trust was collecting and using data about performance to assure itself that quality and safety were satisfactory. The direction of travel could not be determined due to the contradictory nature of the data. Information was not always robust. The board needed to ensure that their decisions were implemented and brought about positive improvement.
  • Performance improvement tools and governance structures had not facilitated effective learning or brought about improvement to practices in all areas.
  • Key mandatory training was below acceptable levels. Many staff had not received regular supervision and appraisal.
  • A lack of availability of beds meant that people did not always receive the right care at the right time and sometimes people had been moved, discharged early or managed within an inappropriate service.
  • Community and crisis teams’ targets for urgent and routine assessments following referral were not always being met in all areas.
  • The poor performance of the single electronic records system had a negative impact had on staff and patient care.
  • There were errors in the application of the Deprivation of Liberty Safeguards and the Mental Health Act.

However:

  • Morale was found to be good across the trust. This was supported by the staff survey and the staff element of the Friends and Family Test.
  • We observed some positive examples of staff providing emotional support to people.

On the basis of this report we are recommending that the trust is placed into special measures.

Inspection carried out on 12 to 22 July 2016

During a routine inspection

This report describes our judgement of the quality of care provided by Norfolk and Suffolk NHS Foundation Trust. Where relevant we provide detail of each core service, location or area of service visited.

We rated Norfolk and Suffolk NHS Foundation Trust as requires improvement overall because:

  • We found that whilst there had been considerable progress since 2014, the service was not yet safe in all areas, fully effective or responsive at this trust. The board needed to take further and more immediate action to address areas of inadequacy.
  • The trust had reorganised its governance processes and began to use quality information to inform performance. However, the board needed to ensure that their decisions were implemented and brought about positive improvement.
  • We found that whilst performance improvement tools and governance structures were in place these had not always facilitated effective learning or brought about improvement to practices.
  • We had a number of concerns about the safety of some services at this trust. These included unsafe environments that did not promote the dignity of patients; insufficient staffing levels to safely meet patients’ needs; inadequate arrangements for medication management; concerns regarding seclusion and restraint practice.
  • The trust did not have effective systems to record whether staff had received their mandatory training. Many staff had not received regular supervision and appraisal.
  • A lack of availability of beds meant that people did not always receive the right care at the right time and sometimes people had been moved, discharged early or managed within an inappropriate service.
  • Whilst access to a single record had been addressed by the application of a single electronic system, we were very concerned about the performance of this system and the impact this had on staff and patient care.

However:

  • The board and senior management had developed a vision with strategic objectives in partnership with staff and patients and had assumed a leadership role and style that was making a difference.
  • Morale was found to have significantly improved across the trust. This was evidenced by the staff element of the Friends and Family Test which indicated that there had been an increasing level of staff satisfaction since 2014.
  • The trust had undertaken improvement to the environment at some services.
  • The trust had improved systems for recording and learning from incidents.
  • Overall we saw good multidisciplinary working and generally people’s needs, including physical health needs, were assessed and care and treatment was planned to meet them.
  • We observed some positive examples of staff providing emotional support to people.

Throughout and immediately following our inspection we raised our concerns with the trust. The trust senior management team informed us of a number of immediate actions they intended to take to address our concerns.

Inspection carried out on 20-25 October and 6 November 2014

During a routine inspection

When aggregating ratings, our inspection teams follow a set of principles to ensure consistent decisions. The principles will normally apply but will be balanced by inspection teams using their discretion and professional judgement in the light of all of the available evidence.

This report describes our judgement of the quality of care provided within this core service by Norfolk and Suffolk NHS Foundation Trust. Where relevant we provide detail of each location or area of service visited.

Our judgement is based on a combination of what we found when we inspected, information from our ‘Intelligent Monitoring’ system, and information given to us from people who use services, the public and other organisations.

Where applicable, we have reported on each core service provided by Norfolk and Suffolk NHS Foundation Trust and these are brought together to inform our overall judgement of Norfolk and Suffolk NHS Foundation Trust.

We rated Norfolk and Suffolk NHS Foundation Trust as inadequate overall because:

  • We found that there was not a safe, effective or responsive service at this trust and the board needs to take urgent action to address areas of inadequacy.
  • While the board and senior management had a vision with strategic objectives in place staff did not feel fully engaged in the improvement agenda of the trust. Morale was found to be very poor across the trust and staff told us that they felt let down by management.
  • The trust had been involved in a number of initiatives to engage with staff. However, staff told us that leadership from above ward level was not visible or accessible to them. Staff told us that they did not feel engaged in the improvement agenda.

  • Despite the trust collecting data there was little evidence of this being used to inform performance. The board could not assure us that it knew how the trust was performing and how decisions were implemented or impacted on quality. We found that while performance improvement tools and governance structures were in place these had not always facilitated effective learning or brought about improvement to practices.
  • Throughout this inspection we heard from service users, carers and local user groups who felt that they had not been effectively engaged by the trust in planning and improvement processes.
  • We had a number of concerns about the safety of this trust. These included unsafe environments that did not promote the dignity of patients; insufficient staffing levels to safely meet patient’s needs; inadequate arrangements for medication management; concerns regarding seclusion and restraint practice.
  • We were also concerned that while the trust had systems in place to report incidents, improvement was needed to ensure learning or action.
  • A large number of staff had not received their mandatory training and many staff had not received regular supervision and appraisal.
  • A lack of availability of beds meant that people did not always receive the right care at the right time and sometimes people may have been moved, discharged early or managed within an inappropriate service.

However:

  • Overall we saw good multidisciplinary working and generally people’s needs, including physical health needs, were assessed and care and treatment was planned to meet them.
  • We observed some positive examples of staff providing emotional support to people, despite the challenges of staffing levels and some poor ward environments.

It is our view that the trust needs to take significant steps to improve the quality of their services and we find that they are currently in breach of regulations.

Throughout and immediately following our inspection we raised our concerns with the trust. The trust senior management team informed us of a number of immediate actions they intended to take to address our concerns.

Intelligent Monitoring

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up.

Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.


Joint inspection reports with Ofsted

We carry out joint inspections with Ofsted. As part of each inspection, we look at the way health services provide care and treatment to people.


Mental Health Act Commissioner reports

Each year, we visit all NHS trusts and independent providers who care for people whose rights are restricted under the Mental Health Act to monitor the care they provide and check that patients' rights are met. Immediate concerns raised by patients on those visits are discussed, if appropriate, with hospital staff.

Our Mental Health Act Commissioners may carry out a number of visits to each provider over a 12-month period, during which they talk to detained patients, staff and managers about how services are provided. In the past, we summarised themes from the visits and published an annual statement followed by the provider's response where applicable. We are looking at different ways to indicate the outcomes of our monitoring in the future.