Norfolk and Suffolk NHS Foundation Trust

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• 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

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. At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant people’s outcomes were consistently good, and people’s feedback confirmed this.

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.

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

We reviewed 23 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 focused. Staff recorded patients’ views in care plans. Care plans were written in the patient’s voice and were written in a way that would be understood by the patient group. Treatment goals were clear within the care plan, for example, 'improve my mental wellbeing so I can feel like myself again' and included information about family or important people in the patient’s life. Care plans included warning signs of deterioration, for example 'I will isolate myself in my room and will eat and drink less’.

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. Physiotherapist assessments included if patients were able to mobilise independently, and any support needed.

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 regular physical health monitoring.

The trust 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 and current 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 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, dietitians and support workers.

Wards all had access to a range of activities and groups to promote age-appropriate stimulation for the client group. Groups and activities included walking, gardening, pamper and grooming, therapy animals, relaxation and music groups, crochet, knit and natter and singalongs.

Wards used a butterfly approach, this meant patients received regular short one-to-one interactions throughout the day. Laurel ward had a full-time occupational therapist working Monday to Friday and 1 activity worker who worked the 7-day period to enable activities to be supported at the weekends. Laurel ward promoted social inclusion in the community and attended Dementia friendly groups and activities at the local theatre.

Wards had access to joint and specialist sessions including relaxation groups, mindfulness sessions, Psychology joint sessions, art Psychotherapy, recovery and wellbeing-based groups.

Patients also had access to rummage boxes, which included newspapers and magazines on the ward. Other activities were available, such as reminiscence items, colouring pens and books, jigsaw puzzles, knitting and items for daily-living tasks such as nail care, dusting and polishing.

The service had a robust audit programme in place. Staff participated in both local and national clinical audit. Topics included therapeutic observations, risk assessments, physical health and falls prevention. The service participated in national audits on care at the end of life.

The trust worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

Wards for older people with mental health problems worked closely with a range of partner organisations to ensure safe, effective, and timely care for patients, with a particular focus on integrated working, discharge planning, and holistic care. This included collaborating with older adult mental health services in other NHS mental health trusts. These partnerships supported shared learning, the exchange of best practice, and service improvement through peer collaboration.

The trust had good links with the local acute hospital who provided end-of-life training for inpatient staff, to support in strengthening staff confidence and competence in delivering compassionate, high-quality care to patients approaching the end of life.

The trust received support from the local authority, with a dedicated social worker co-located on the Julian Hospital site. This enabled timely social care input and joint decision-making, which included attendance at weekly multidisciplinary team meetings. The trust told us this integrated approach had improved discharge planning and coordination, resulting in a more efficient discharge processes and a reduction in avoidable delays.

Abbeygate ward maintained a separate, structured weekly multidisciplinary team (MDT) handover meeting. This MDT involved the full team, including consultants, medical staff, nurses, clinical nurse specialists, pharmacy, the Mental Health Act team, discharge coordinator, occupational therapy, and psychology. During this meeting, staff had a comprehensive discussion of each patient’s treatment plan and discharge planning to ensure a coordinated and person-centred approach.

Information relating to care, advocacy access, activities, communication needs and feedback on care were displayed on the ward notice board for patients.

The trust supported people to manage their health and wellbeing to maximise their independence, choice and control. Staff supported people to live healthier lives.

Staff identified patients’ physical health needs and recorded them in their care plans. Staff conducted checks of each patient’s pulse, temperature, weight, height and blood pressure regularly.

Staff made sure patients had access to physical health care, including specialists as required. Patients were seen promptly by a doctor when they felt unwell.

Beach, Blickling, Reed, Rose and Sandringham wards at Julian Hospital carried out joint working with the local Community Health service, supporting physical health needs of the patient group. Julian Hospital held bi-weekly joint MDT meetings to review complex cases, which enabled shared problem-solving and access to specialist advice. This collaboration included access to virtual wards, which enhanced continuity of care and supported patients who required ongoing physical health monitoring alongside their mental health treatment.

Ward activities helped promote a healthy lifestyle for patients with age-appropriate activities for patients to take part in, including access to gym facilities, walking groups, gardening and chair exercises.

The trust 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.

Staff continuously monitored patients’ health, their mental state and well-being. There were numerous patients on enhanced observations and twice daily handover meetings. Staff noted details of patients’ sleep, food and fluid intake, personal hygiene, compliance with medication, and engagement in activities.

Staff used recognised rating scales to assess and record the severity of patients’ conditions and care and treatment outcomes.

The trust told people about their rights around consent and respected these when delivering person-centred care and treatment.

Staff assessed each patient’s capacity to consent to admission and treatment on admission. Capacity was monitored and recorded at multidisciplinary team meetings.

Staff took all practical steps to enable patients to make their own decisions. For patients who might have impaired mental capacity, staff assessed and recorded capacity to consent appropriately on a decision-specific basis.

Staff complied with the Mental Health Act 1983, ensuring patients’ rights were upheld and clearly communicated both verbally and in writing, including the right to appeal. Section 132 rights were explained on admission and revisited regularly, or when there were changes to Mental Health Act status, Responsible Clinician, or treatment plans. All readings were consistently documented in patients care records. Consent to treatment forms were present, well-organized, and accurately completed. No concerns were identified in the records reviewed.

Staff engaged with patients’ families to understand each patient’s history and interests; this is reflected in patient’s care plans.