Norfolk and Suffolk NHS Foundation Trust

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question Requires Improvement. At this assessment the rating has changed to Good.

This meant people were safe and protected from avoidable harm.

This service scored 69 (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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

There were systems in place for the recording and reporting of incidents. The service used the Patient Safety Incident Review Framework (PSIRF) for investigation of serious incidents. Incidents were discussed in daily safety huddles, weekly locality safety meetings and could then be taken to the trust-wide safety group meeting.Issues from weekly meetings were escalated into a monthly Learning from Outcomes Group which are attended by service leaders. Agenda items included reviews of patient safety incidents, patient safety alerts, trust policy and service user feedback.

Lessons learnt from incidents were shared across the service by email and verbally in handover meetings. There were also trust-wide safety alerts and a monthly briefing pack shared. Staff were able to provide examples of learning from incidents.

Staff we spoke with knew how to report incidents or accidents using the providers internal reporting system. Staff told us they received emails if there had been an incident whilst they were not at work and that they were also discussed during handover meetings. Staff confirmed they debriefed following accidents or incidents and that patients were involved in debrief when they had been involved in an incident.

Staff were up to date with mandatory trainingon the Patient Safety Incident Response Framework (PSIRF) with 99% of staff having completed patient safety training at both levels 1 and 2.

Patients and carers we spoke with were aware of how to raise any concerns with the service and felt safe to do so.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

The service’s processes promoted people living free from abuse, neglect, and avoidable harm. There were clear systems, policies, and practices in place to ensure people were protected. We saw evidence of a comprehensive local safeguarding procedure and a range of policies designed to safeguard both adults and children from harm. These measures supported a culture of safety and accountability across the service.

Staff confirmed they had received safeguarding training and understood how to report any concerns. They were aware of who the safeguarding lead for the service was and knew how to escalate issues or seek advice when needed. Safeguarding was discussed within the network governance meetings.

Staff were kept up to date with mandatory training for safeguarding adults and children with training compliance rates of 94% for safeguarding children level 3 and 95% for safeguarding adults level 3.

The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We reviewed 15 patient records and saw that staff involved patients to complete a thorough, individualised risk assessment on admission to the service and updated these regularly. Psychology staff completed HCR-20 (Historical-Clinical-Risk Management-20) risk assessments and reviewed these every six months. Staff completed Model of Human Occupation Screening Tool(MOHOST) and individual supervised internet access risk assessments.

Staff co-produced positive behaviour support plans with patients to identify causes of behaviours that challenge and provide strategies to manage these.

Risks were routinely reviewed during handover and multi-disciplinary review meetings, with any changes clearly documented in the daily notes of patient care records. This supported a collaborative and person-centred approach to risk management, ensuring care remained responsive to individuals’ evolving needs.

We reviewed the service incident data for the 6 months prior to inspection. The service had recorded 140 incidences of restraint involving 40 patients with the majority of these occurring on Whitlingham Ward. 15 incidences of restraint had resulted in the use of rapid tranquilisation, all of which were on Whitlingham Ward.

The service reviewed risk assessments and restrictive interventions as part of the network governance meeting.

The use of restrictive interventions and the use of any blanket restrictions on the ward were regularly reviewed by the reducing restrictive practice group. We saw in patient care records that staff completed individual risk assessments for patients to have access to sharp items and the internet.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The service completed regular risk assessments of the environment including ligature risk assessments, clinical environmental risk assessments, site specific risk assessments and trust wide risk assessments.

We observed that the ceiling tiles in a ward bathroom could be lifted and patients could potentially access the space above to hide restricted items or to attempt to tie a ligature. Staff confirmed that this was a known risk and following our visit the trust confirmed they were looking at changes to the ceiling tiles to make them more secure.

We also observed that the seclusion room on one ward has a low ceiling with a reachable ceiling mounted smoke sensor that could easily be removed and weaponised or used to make a fixed ligature point. The trust confirmed that they were aware of the risk and although this was partially mitigated through staff observation of seclusion, they were taking steps to address this.

The layout of Blakeney ward meant that staff could not observe patients in all parts of the ward due to the bedroom corridors not being in line of sight of the staff office or communal areas. Staff told us they mitigated this with frequent observations of the bedroom corridors every 15 minutes as well as the use of mirrors and CCTV.

Catton and Drayton wards design enabled easier patient observation. Staff also used mirrors, direct observation, and CCTV to enhance visibility and safety.

All bedrooms were single occupancy lockable rooms, and patients had wristbands that enabled them to unlock their bedroom door. Patients had access to nurse call systems in their bedrooms. Catton and Drayton wards had en-suite bedrooms with additional bath facilities for patients who preferred baths to showers. Blakeney ward did not have en-suite facilities but had sufficient showers, bath and w.c. facilities for patients.

Clinic rooms on all three wards were secure, clean and safe. All essential equipment was present, calibrated and in good working order, and we saw that staff used green clean stickers. The service used an electronic system to monitor emergency equipment and medicines that alerted staff when anything needed updating or replacing. The service used an external electronic system to monitor clinic room temperatures that alerted staff if the temperature was too high.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Managers calculated the number and grade of nurses and healthcare assistants required for each shift. The service reviewed staffing needs every six months using the Mental Health Optimisation Staffing Tool (MHOST)

The service held a safety huddle meeting each morning where managers reviewed the number of staff available for the day and whether there were any gaps in shifts that needed filling. Where required managers used bank staff and occasionally agency staff to fill shifts. There had not been any unfilled shifts in the 3 months before inspection.

At the time of inspection the service had 1 full time nurse vacancy and 3 full time healthcare support worker vacancies across the 5 wards.

The service had a turnover rate of 8% in the year up to inspection against a target of 10%. However, the turnover rate for Foxhall ward was at 11%. Staff sickness rates were 4% against a 4.9% target.

Managers provided new staff with induction, and all staff had regular supervision and annual appraisals. At the time of inspection 97% of staff were up to date with managerial supervision, 100% of staff were up to date with clinical supervision and 97% of staff had an annual appraisal in place.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Systems and processes were in place to ensure the safe prescription, storage, and administration of medicines. The service used an electronic prescribing system which was effective in reducing medication errors and enabling out of hours prescribing.

Medicines including controlled drugs were stored appropriately and pharmacists conducted medication audits 2 or 3 times per week.

We reviewed 15 medication records and saw that all medicines had been administered as prescribed.

Staff reviewed the effects of medication on patient’s physical health regularly and in line with National Institute for Health and Care Excellence (NICE) guidance. Patients we spoke with confirmed that they were involved in discussions about their medicines and understood what medicines they were taking and why.

The physical health team monitored patients prescribed high-dose antipsychotics, conducting regular blood tests in line with NICE guidance to identify and manage potential side effects promptly.

Nursing staff responsible for the administration of medicines were appropriately trained with 96% of staff having completed up to date medicines management training.