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

Safe

Safe rating: Requires Improvement
This means we looked for evidence that people were protected from abuse and avoidable harm.
At our last assessment we rated this key question Requires Improvement. At this assessment the rating has remained Requires Improvement.
This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.
The service was clean, well equipped, well furnished, well maintained and fit for purpose. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. The service managed patient safety incidents well. However, the service remained in breach of the Health and Social Care Act regulations (2008) related to mandatory training and high staff sickness. (Regulation 18(1)).

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Learning Culture
Quality Statement Score: We scored the service as 3. The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.
There were no serious incidents recorded on the ward in the last 12 months. There was a robust handover process in place on the ward that reviewed risk. Staff compliance with patient safety training was 100%.
Staff reported serious incidents clearly and in line with provider policy. We spoke with 4 members of staff; all knew what incidents to report and how to report them.
Staff understood the duty of candour, and we saw an example of a debrief held with a patient after a medication error.
 

Safe Systems, Pathways and Transitions
Quality Statement Score: We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.
The service’s referral and admission processes ensured that all essential information about the patient was received to determine if the patient’s needs could safely be met. The service used a comprehensive preadmission process. Care plans evidenced regular assessments and updates from the multi-disciplinary team (MDT).
Staff ensured working with both internal and external partners was positive and meaningful. Weekly meetings with the Suffolk and North East Essex Integrated Care Board and Suffolk County Council were held to coordinate safe and person-centred discharges.
Staff undertook patients discharge planning from admission and this was reviewed regularly. However, 1 care plan we looked at did not include a crisis management plan for when the patient was on leave in the community.
 

Safeguarding
We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They 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 service shared concerns quickly and appropriately.
The service had a safeguarding policy and clear processes in place for staff to follow.
Staff received training on how to recognise and report abuse, appropriate for their role. All staff completed mandatory safeguarding training modules and compliance was between 96% and 100%.
Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies.
Staff followed safe procedures for children visiting the service.
 

Involving People to Manage risks
We scored the service as 3. The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. Staff assessed and managed risks to patients and themselves well and followed best practice in anticipating, de-escalating and managing challenging behaviour. Staff used restraint and seclusion only after attempts at de-escalation had failed. The ward staff participated in the provider’s restrictive interventions reduction programme. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.
We looked at 2 care plans and risk assessments. All patients had a risk assessment completed at admission and regular updates were recorded. However, it was noted that crisis plans could have been more comprehensive. This was raised with the service who made immediate updates and provided assurance this has been addressed.
There were no incidents of restraint recorded for any patient.
Staff involved patients in care planning and risk assessment, this was shown by evidence in their care plans and participation in multidisciplinary team reviews.
Staff enabled patients to give feedback on the service they received. Community meetings were held each morning, and the service had a ‘you said we did’ culture of care project where patients had suggested improvements to the activity programme.
All patients had access to an Independent Mental Health Advocate (IMHA) during their stay at the hospital. Information about how to access the advocate was displayed around the ward.
 

Safe environments
We scored the service as 3. The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.
Staff did regular risk assessments of the care environment. We toured the ward and observed that it was clean, open and bright.
Staff could not observe patients in all parts of the wards and outside space. However, the service had fitted convex mirrors and CCTV to monitor communal areas.
The ward complied with guidance on eliminating mixed-sex accommodation.
Clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly. We identified that clinic room keys were not colour coded for easy identification. We raised this with the service who rectified this immediately.
The service had adequately mitigated ligature risks.
Each patient had their own bedroom, which they could personalise. Bedrooms were clean and some had ensuite facilities. There were communal bathrooms available for patients that did not have an ensuite room.
Staff used a range of rooms and equipment to support treatment and care. The ward had a clinic room, and rooms that could be used for group work, therapy and activities.
 

Safe and Effective Staffing

We scored the service as 1. The evidence showed significant shortfalls. The service did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.
The service establishment staffing was 10 registered nurses and 10 healthcare assistants. There was 1 vacancy for a registered nurse and 1 vacancy for a healthcare assistant.
When necessary, managers deployed agency and bank nursing staff to maintain safe staffing levels. Since December 2025, bank staff were used 113 times to cover sickness, absence or vacancies.

Managers had calculated the number of nurses and healthcare assistants required.
Managers gave each new member of staff a full induction to the service before they started work.

Staff had mostly kept up to date with their mandatory and essential training. Overall, compliance was between 65% and 100%. There were 2 pieces of training with a compliance rate of less than 75%, that being Physical Intervention Refresher Adult Services and Resuscitation - Level 3 - Immediate Life Support (ILS).

At the time of inspection, the staff sickness rate was high, between 7.1% and 9.5% over the last 12-month rolling period.

The service was in breach of the Health and Social Care Act regulations (2008) related to mandatory training and staff sickness (Regulation 18(1)).

Infection Prevention and Control
We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.
Staff maintained equipment well and kept it clean.
All ward areas were clean, had good furnishings and were well-maintained.
Cleaning records were up to date and demonstrated that the ward areas were cleaned regularly.
Staff followed infection control policy, including handwashing, this was evident in the twice-yearly handwashing audit that identified 100% compliance. Hand gel was available at the ward entrance. Compliance levels for essential training in infection control was 96%.
 

Medicines Optimisation
We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning.

Staff reviewed the effects of medication on patients’ physical health regularly and in line with NICE guidance.

Staff mainly followed good practice in medicines management in line with national guidance. However, we saw that one patient’s medication was not being dispensed in line with national guidance. We were assured by the trust that this was rectified after the issue was raised with them.