- SERVICE PROVIDER
Norfolk and Suffolk NHS Foundation Trust
This is an organisation that runs the health and social care services we inspect
Assessment report published 24 March 2026
Contents
Ratings - Wards for older people with mental health problems
Our view of the service
We carried out an inspection of the trust’s wards for older people with mental health problems on 3rd and 4th February 2026 and 5th March 2026. We assessed 34 quality statements across Safe, Effective, Caring, Responsive and Well Led key questions.
The trust has 8 wards for older people with mental health problems across Norfolk and Suffolk.
The inspection team comprised of 2 CQC inspectors, 1 senior specialist, 1 specialist advisor and 1 operations manager.
During the inspection we:
- Visited all 8 wards and reviewed the ward environments and clinic rooms.
- Spoke with 27 staff members of various grades and roles.
- Spoke with 16 patients and 5 carers of patients.
- Reviewed 23 care records and 62 medicines administration records for patients within the service.
- Reviewed a range of information including policies, meeting minutes and service data.
The service was last inspected between September and November 2022, we did not rate the service as we did not inspect caring or well led key questions. Safe was rated as inadequate and effective and responsive were rated as good.
At our last inspection we found breaches relating to ligature risks on Blickling and Sandringham wards, and patients who were identified as a risk of suicide or self-harm were able to access rooms containing high risk items such as electric beds. We found issues with the recording and quality of patient observations, and incidents were not responded to in a timely way or in line with trust systems and processes.
The service had made improvements in these areas and was no longer in breach of regulations.
At this inspection we rated this service as good in each domain, and good overall.
People's experience of this service
We spoke with 16 patients and 5 family members. Patients told us that staff were supportive and kind, patients liked their rooms and they said they had comfortable beds. Patients said they knew and understood what medication they were taking. Family members told us that staff were always available to speak with, they were made tea and coffee when they visited and family members said they appreciated that they could visit every day and that all wards were flexible with visiting times.
During our visit, we observed the experiences of individuals living with dementia and complex needs who were unable to provide verbal feedback. Our observations showed that staff treated people with dignity and respect, and staff knew and understood the patients they were supporting. The service prioritised person-centred care by offering meaningful choices regarding nutrition, activities, and daily environments.
We reviewed feedback from 56 patients between August 2025 to January 2026. Feedback was positive, with 84% of patients saying that care was either good, or very good. Feedback included that wards were clean and comfortable with nice bedrooms. However, there were mixed reviews on food. Patients fed back that staff were friendly but that sometimes wards were short staffed and sometimes agency staff who were not familiar with the ward were used. One patient said that even when staff were stretched due to the volume of care needed on the ward the standard of care did not fall.