Norfolk and Suffolk NHS Foundation Trust

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question Good. At this assessment the rating has remained Good.

This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Staff spoke positively about local leadership. They described leaders as approachable, accessible and supportive, and noted that senior leaders were visible on the wards and attended the daily safety huddle meeting. Leaders demonstrated a clear understanding of the service and its challenges, and staff felt confident that they could raise concerns and be listened to.

The service had a medical director vacancy at the time of the inspection, and some staff told us that there was no contingency in place for covering this vacancy. However, the trust was actively recruiting to this role.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff told us they knew how to raise a concern and felt comfortable doing so. They were aware of the service’s whistleblowing policy and the Freedom to Speak Up Guardian.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

We reviewed examples of governance and staff meeting minutes. There was a clear framework outlining what must be discussed at staff and team meetings to ensure essential information, such as learning from incidents and complaints, was shared.

The service had clear governance processes in place to review and take action on the results of audits, incidents and complaints.

The trust had a risk register at service level that accurately reflected the current risks. Managers and staff could access the risk register and raise concerns when required.

Staff had access to the equipment and information technology needed to do their work. Staff told us that the current electronic care records system was not the simplest or most efficient to use but the trust was tendering for a new electronic system. The electronic prescribing system was highly effective and easy to use.

The service had plans in place for emergencies including major incident contingency plans. At the time of inspection the wards at Northside House had a contingency plan in place as the drinking water supply had been contaminated. The service had immediately closed the water supply and arranged additional bottled water for patients and staff.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The service had a strong focus on continuous learning, innovation and improvement across the organisation and local system. They always encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

The service had a number of quality improvement projects in place as part of their quality improvement programme. Drayton ward was part of the NHS England Culture of Care programme, a national quality improvement initiative to help wards become safe, therapeutic, and equitable environments. Drayton ward had implemented 5 initiatives around activity, engagement and self-care which had resulted in a reduction in incidents and restraint, and an increase in engagement and improved outcomes.

There were a number of projects in place across the service aimed at increasing physical health, including improved access to primary healthcare services for all wards and cervical screening and a women’s health group for patients on Whitlingham ward.

The trust had projects in place as a result of their ‘Listening in Action’ programme that included supporting staff affected by violence, reducing stress and burnout, and improved recruitment process which also incorporated patient involvement in interview panels.

Staff could access professional development opportunities and specialist training. The trust had implemented a dedicated career pathway for support workers and opportunities were available for nursing preceptorships, assistant practitioner training and leadership development.