Norfolk and Suffolk NHS Foundation Trust

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

This service scored 79 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

We reviewed 15 care records as part of our assessment. Staff completed a comprehensive assessment of patients mental and physical health needs on admission.

Staff developed care plans that met the patients’ needs identified during their assessment and care plans were personalised, holistic and recovery focussed. Staff recorded patients’ views in care plans, and each care plan included a ‘people involved in my care’ section that recorded which family and carers patients wanted involved in their care.

Care plans included input from different professionals including psychologists, occupational therapists, nurses and physical health professionals. Care plans included activity plans to meet health and social needs.

Staff assessed patients’ physical health needs in a timely manner after admission. The service employed a physical health team who completed physical health assessments, physical health care plans and monthly physical health monitoring.

The service always planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation. They worked to develop evidence-based good practice and standards.

Staff provided a range of care and treatment interventions suitable for the patient group. The interventions were those recommended by, and were delivered in line with, guidance from the National Institute for Health and Care Excellence.

The psychology team had developed a range of pathways to meet patient needs including mental health, trauma, substance misuse and an adapted pathway for learning disability and autism. Psychology staff delivered a number of therapeutic interventions that included cognitive behavioural therapy, dialectic behavioural therapy, schema therapy, risk reduction work tailored to individual need and eye movement desensitisation and reprocessing (EMDR). Psychology staff also completed positive behaviour support plans and risk of violence assessments and could offer neurodivergence assessments for patients who required them,

The team included or had access to the full range of specialists required to meet the needs of patients in the service including doctors and nurses, occupational therapists, clinical psychologists, dieticians and support workers.

The service provided a range of activities and opportunities to help patients acquire living skills. The Occupational therapy and fitness team completed assessments of living skills and offered sessions including cooking and gardening. Patients at Northside House could access The Mount, which offered woodwork, metal work and horticulture skills training. Patients could make sculptures that were sold to the public and some had roles supporting other patients with learning metal and woodwork. Patients could also work in the Tuck Shop to gain customer service and retail experience and qualifications. Patients received payment of vouchers for some of these work opportunities.

The service offered a variety of social and leisure activities for patients including gym sessions five times a week, a social hub for patients with section 17 leave to access in the evenings, trips out to the local community and weekly ramble groups. Staff also offered a variety of activities on the ward including music sessions, board games and movie nights. Staff and patients cooked a meal together each Sunday.

The service had a robust audit programme in place. Staff participated in both local and national clinical audit. Topics included therapeutic observations, risk assessments, rapid tranquilisation and section 17 leave. The service participated in national audits on the use clozapine and opioid medications.

Staff worked effectively across teams and services to support people, by sharing their assessment of needs when they move between different services.

Staff came together to discuss patients and held regular multidisciplinary meetings.

Teams demonstrated effective collaboration through structured handovers and scheduled multidisciplinary meetings. Shift-to-shift handovers were comprehensive, ensuring that all relevant patient information was communicated clearly. Each patient’s care plan was reviewed during these sessions, and any changes were documented promptly. This process supported continuity of care and enabled staff to identify and manage individual risks effectively.

Staff had effective working relationships with teams outside the organisation including the provider collaborative, the Ministry of Justice and local healthcare providers.

The service supported people to manage their health and wellbeing to maximise their independence, choice and control. Staff supported people to live healthier lives and where possible, reduce their future needs for care and support.

The service employed a physical health team who completed physical health assessments and created care plans to address patients' physical health needs. However, we saw that physical health care plans were not always shared into patient electronic care records. This meant that care plans such as the monitoring of high dose antipsychotic therapy (HDAT) and patient epilepsy care plans were not shared with ward staff.

The service had a contract with a local GP surgery for a dedicated GP to visit the wards weekly.

The service employed a dietitian who worked with patients to increase their knowledge of healthy eating and how diet impacts on physical and mental health.

Ward activities helped promote a healthy lifestyle for patients with patients able to access an onsite gym and local leisure facilities including swimming and football clubs.

The provider routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves.

The service used a number of recognised tools to monitor and improve outcomes for patients including The Historical, Clinical and Risk Management - 20 (HCR -20), the Model of Human Occupation Screening Tool (MOHOST), Dialog + and physical health screening tools including MUST (Malnutrition Universal Screening Tool) and falls assessments.

Staff completed daily continuation notes for each patient, which included an overview of care plans, observations, activities, food and fluid intake, physical health and sleep patterns. Staff discussed any changes of these in daily handover meetings.

We did not look at Consent to care and treatment during this assessment. The score for this quality statement is based on the previous rating for Effective.