Norfolk and Suffolk NHS Foundation Trust

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

This means we looked for evidence that the provider met people’s needs.At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant people’s needs were met through good organisation and delivery.

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 were at the centre of their care and treatment choices and they decided, in partnership with people, how to respond to any relevant changes in people’s needs.

We reviewed 23 care plans and saw that patients were involved in agreeing their care plans and care plans were written in the patients’ voice. Care plans were comprehensive and person-centred, reflecting patients’ individual physical, mental, emotional and social needs.

Family members confirmed they were consistently involved in care, ensuring support was tailored to individual needs.

The trust understood the diverse health and care needs of people and their local communities, so care was joined-up, flexible and supported choice and continuity.

Staff worked as a team to provide care without any gaps. By sharing information across different services, thepatient’s needswere prioritised.

staff had a good understanding of the health and social care needs of the patient group, enabling them to deliver tailored support for age-related conditions such as dementia and mobility limitations. Staff coordinated with internal and external organisations to ensure physical mobility limitations and tissue viability were addressed alongside mental health.

The trust used the "Triangle of Care" model, which integrated family and friends into the care planning process, offering them specialized support groups and Carer Assessments.

The trust supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

Staff made notifications to external bodies as needed. The trust submitted notifications to the Care Quality Commission in accordance with the requirements of their registration. The trust submitted safeguarding referrals to the local authority when required and had a dedicated social worker co-located on the Julian Hospital site. The trust also had a Principal Social Worker role which supported professional practice, learning and interface with the local authority.

Staff ensured carers, families and care co-ordinators were regularly updated about the patient’s progress.

Information governance systems included confidentiality of patient records. Records were maintained in line with the trusts policies and procedures, ensuring personal information was securely safeguarded.

The trust made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. Staff involved people in decisions about their care and told them what had changed as a result.

Patients, relatives and carers knew how to complain or raise concerns. We saw that information about how to make a complaint and how to raise concerns with the Care Quality Commission was available on noticeboards throughout wards.

Patients could give feedback through regular patient meetings on some of the wards. Due to the nature and degree of cognitive impairment, the patients on Laurel, Beach, Rose and Reed wards did not have patient meetings, wards provided information and gained feedback from carers groups and through skilled communication.

The trust received 6 complaints for wards for older people with mental health problems in the 3 months leading up to inspection. Three had been resolved. Complaints were investigated fully; feedback was given, and changes were implemented as a result, for example, carer audits were implemented following a family not feeling involved in treatment.

The trust made sure that people could access the care, support and treatment they needed when they needed it.

The service ensured patients could access care, treatment, and support tailored to their individual needs. Through effective assessment processes, staff identified and removed barriers to care, particularly for individuals with complex needs, enduring mental illness, or protected characteristics under the Equality Act 2010.

Staff made reasonable adjustments for patients – for example, occupational therapists completed thorough assessments and recommended adaptations required, which wards implemented.

Patients had access to both bath and wet room facilities.

Staff planned for patients’ discharge, including good liaison with care managers/co-ordinators. Care plans identified discharge planning, started at the point of admission and was embedded throughout the patients stay. The Multidisciplinary Team (MDT) considered anticipated length of stay, discharge goals, and potential barriers, ensuring discharge was treated as a continuous process rather than a single event.

There were 3 delayed discharges from older people’s mental health wards between August 2025 and January 2026. Two of which have since been discharged to another placement, with 1 patient still awaiting an appropriate placement.

Staff and leaders actively listened to information about people who are most likely to experience inequality in experience or outcomes and tailored their care, support and treatment in response to this.

Staff told us how adjustments were made to accommodate patients with diverse needs. Information was also made available in various formats to ensure accessibility. For instance, patients with dementia benefited from accessible information appropriate to support them such as easy read booklets, communication cards and pictorial cards.

Staff made sure patients could access information on treatment, local service, their rights and how to complain.

The trust had a race equality strategic plan and a Promoting Equality, Diversity and Inclusion policy in place, which staff were aware of. Overall, 97% of staff had completed Equality, Diversity and Inclusion training.

People were supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

Staff developed person-centred care plans that reflected each patient’s unique needs, preferences, and feelings. Patients and carers were active participants in Multidisciplinary Team (MDT) meetings. In instances where patients lacked mental capacity, staff demonstrated a commitment to inclusion, by taking the time to explain care pathways in an accessible manner.

Care for people who are nearing the end of their life, was managed and communicated in a sensitive and dignified way. Staff supported patients to make decisions about their care and treatment and their future, in some circumstances using Do Not Attempt Cardiopulmonary Resuscitation (DNACPR’s). Staff had completed end of life training and built relationships with community nursing teams and hospices.