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

This means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question inadequate. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

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.

All staff knew what incidents to report and how to report them. We spoke with 27 members of staff. Learning was shared among staff during team meetings, on topics, for example, the risk of falls, to reduce the number of incidents and improve safety.

Staff told us that all incidents were recorded on the trusts internal incident reporting system and incidents reported required sign off by a manager within the team, to include management actions and learning points. Incident reports were monitored daily and discussed within the daily safety huddles and weekly assurance meetings. Themes, trends and learning from incidents were reported monthly through the Quality Performance Group report and shared with teams.

Staff understood the duty of candour. They were open and transparent and gave patients and families a full explanation if things went wrong.

Between December 2025 and the inspection, the trust reported 756 incidents across wards for older people with mental health problems. When incidents, such as episodes of aggression, occurred, staff responded promptly, documented incidents accurately, and updated care plans and risk assessments. Staff we spoke with knew what incidents to report and how to report them. Incident numbers were high due to the reporting of all incidents and near misses.

The trust maintained a high standard of safety through monitoring and rigorous assurance frameworks. A strong emphasis was placed on care coordination, so that patient safety and information remained consistent even during transfers between services or wards.

The service used robust pre-admission assessments and referral protocols to ensure that patient requirements fell within safe clinical limits. Care plans demonstrated multi-disciplinary team (MDT) involvement, ensuring that clinical oversight was continuous and responsive to changing patient needs.

Staff effectively coordinated with relevant health and social care partners to maintain clinical continuity both during and after the patient’s admission. Care records were person-centred and comprehensive, providing referrals to external specialists, including GPs, and secondary care providers, to ensure all holistic needs were addressed.

The trust 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 trust shared concerns quickly and appropriately.

Staff were trained in safeguarding, knew how to make a safeguarding alert, and did that when appropriate. Staff were able to contact safeguarding leads within the trust for support and advice.

Safeguarding adults and children training compliance were all above the trust target of 85% compliance. The only exception was for Safeguarding adults’ level 3 training on Sandringham ward where the compliance was 73%. This equated to 5 staff members who all had safeguarding level 3 training booked to complete by March 2026.

Staff we spoke with could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act.

Staff worked in partnership with other agencies and took appropriate action to protect patients from abuse, neglect, or discrimination and worked collaboratively with external agencies when required, for example, the local authority safeguarding team.

Mental Capacity Act

90% of staff had completed training in the Mental Capacity Act.

Staff had a good understanding of the Mental Capacity Act, in particular the 5 statutory principles.

The trust had a policy on the Mental Capacity Act, including deprivation of liberty safeguards. Staff were aware of the policy and had access to it.

Staff knew where to get advice from within the trust regarding the Mental Capacity Act and took all practical steps to enable patients to make their own decisions

The trust 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.

Staff assessed and managed risks to patients and themselves well and followed best practice in anticipating, de-escalating and managing challenging behaviour. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. We reviewed 23 risk assessments as part of our inspection. Staff knew about any risks to each patient and acted to prevent or reduce risks. Potential risks for patients included risk of falls, self-harm and self-neglect. Staff had a good understanding of patients’ histories.

Staff involved patients in care planning and risk assessment. We saw this evidenced in care plans by staff using the patient’s voice.

The trust reported 83 restraints via the incident reporting system in the 3 months leading up to inspection, none of these were prone. Eleven of the episodes of restraint resulted in rapid tranquilisation being used. The use of restraint on older people’s mental health wards was reducing, with 31 episodes of restraint in November 2025 and 24 episodes of restraint in January 2026. Overall, 98% of staff had completed breakaway training and 78% of staff had completed physical intervention training specific to older people.

Wards had ligature information packs, created specifically for each ward. Clinical Environmental Risk Assessments had been completed for each ward in August 2025, which included ligature risks.

Individual patient risk assessments had been completed and additional observations put in place for ward personalised Ligature Risk Registers and all wards had ligature maps in place in staff offices, identifying areas with ligature risks.

Ward specific environmental risk assessments included Inpatient hot drink provision and process, Moving and Handling and Violence and Aggression towards inpatient staff.

Patients had access to an Independent Mental Health Advocate (IMHA). Information about how to access the advocate was displayed around wards and given to patients and their families as part of the admission process

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

People were cared for in safe environments that were designed to meet their needs. Facilities, equipment and technology were well-maintained and consistently supported staff to deliver safe and effective care. Following our inspection in 2022, where we identified environmental ligature risks on Blickling ward, the ward was closed in October 2022 and redesigned to ensure all the issues found at the last inspection had been addressed and were no longer present.

At previous inspections we found Laurel Ward at Carlton Court was not dementia friendly. The trust had made improvements to the ward environment to ensure the privacy and dignity of patients and meet dementia friendly guidance. The ward had followed guidance from the Kings fund for maintaining a dementia friendly ward.

Monthly ligature audits were completed by the health and safety champion jointly with the matron or ward manager by the middle of every month and were then submitted to the risk review team. This included the communal gardens and the ward gardens at Carlton Court and Laurel ward, which were only accessible under supervision.

We toured all wards and observed that they were spacious, clean and well-maintained, well-furnished and fit for purpose. The trust was in the process of redecorating some wards at the time of inspection.

Staff could not observe patients in all parts of the wards and outside space. However, the service had fitted convex mirrors to monitor communal areas, used enhanced observations to support patients with additional risks and had CCTV covering communal areas.

Electrical beds on wards had been replaced and had removable charging cables, beds that required charging were charged whilst patients spent time in communal areas, individual risk assessments were in place to manage this.

Wards complied with mixed sex accommodation guidelines, mixed sex wards had access to en-suite bathrooms, females and males had separate corridors and wards had female only lounge areas.

The trust 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.

Patients we spoke with said there were always staff visible on the wards, during the inspection we could see the ward was fully staffed, and there were staff visible in all ward areas supporting patients throughout the inspection.

The trust ensured there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. Staff 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).

Staff had received and were up to date with appropriate mandatory training. The training was appropriate for the patient group using the service. Overall, the average of staff compliance with mandatory training was 93%. Specialist training for the patient group included Physical Intervention Refresher Older Persons training and Oliver McGowan Learning Disability and Autism Tier 1 training.

The average supervision compliance rate for older people’s mental health wards was 95%. The average appraisal compliance rate for older people’s mental health wards was 97%.

When bank or agency staff were used, they were familiar with the ward and staff employed by the trust were prioritised for shifts. To ensure safe staffing levels wards held daily management huddles where support was provided to wards including allocation of management working clinically and support from neighbouring wards if needed.

Staff turnover levels were low, with no staff leaving older people’s mental health wards in December 2025. Staff turnover levels were below the trust’s staff turnover target rate of 10% in the three months leading up to inspection

The trust assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The service assessed and managed the risk of infection, detected and controlled the risk of it spreading and shared any concerns with appropriate agencies promptly.

Staff maintained equipment well and kept it clean.

All ward areas and clinic areas were clean and well maintained.

Cleaning records were up to date and demonstrated that all areas of the hospital were regularly cleaned.

Staff followed infection control policy, including handwashing. Hand gel was available throughout wards. Overall, 90% of staff had completed Infection Prevention and Control Level 2 training.

The trust 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 regularly.

We reviewed 62 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.

Nursing staff responsible for the administration of medicines were appropriately trained with 91% of staff having completed up to date medicines management training. Overall, 86% of staff had training in physical health and 84% of staff overall, had been trained in immediate life support. However, only 73% of staff on Laurel ward were up to date with immediate life support training