Norfolk and Suffolk NHS Foundation Trust

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

WELL LED

Well led rating: Good
This means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.
At our last assessment we did not rate this key question. At this assessment the rating was Good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.
 

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Shared direction and culture
We scored the service as 3. The evidence showed a good standard. The service had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.
Staff were aware of the trust’s values and demonstrated these values in their day-to-day work.
The trust’s senior leadership team had successfully communicated the trust’s vision and values to the frontline staff in this service.
Staff felt supported by senior leaders who were visible and approachable.
 

Capable, compassionate and inclusive leaders
We scored the service as 3. The evidence showed a good standard. The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.
Leaders had the skills, knowledge and experience to perform their roles.
Staff told us leaders were visible in the service and approachable for patients and staff.
Leaders had a good understanding of the services they managed. They could explain clearly how the teams were working to provide high quality care.
The trust provided development opportunities for staff, including phlebotomy training and the opportunity for a member of staff to become a physical health instructor. We saw examples of management development opportunities, as well as staff being given protected time to complete professional training courses.
 

Freedom to speak up
We scored the service as 3. The evidence showed a good standard. The service fostered a positive culture where people felt they could speak up and their voice would be heard.
Patients and carers had opportunities to give feedback on the service they received, with give feedback on care advice displayed on the ward. Community meetings took place daily where patients could raise concerns.
The trust had a Freedom to Speak Up Guardian, and staff felt comfortable raising concerns and were confident they would be supported.
We saw positive feedback from staff praising their placement experience at the service.
 

Workforce equality, diversity and inclusion
We scored the service as 3. The evidence showed a good standard. The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.
There were equality and diversity champions within the service.
The trust had a race equality strategic plan in place to work towards dismantling racism.
There were Staff Equality Networks within the Trust, includingREACH Network Group, Ability Network Group, Lived Experience (Mental Health) Employee Network Group, LGBT + Network Group, Neurodiversity Network Group, Carers Network Group and Women's Network Group.
The provider undertook equality monitoring of staff within the service to ensure it was diverse in its make-up and representative of the patient group.

Governance, management and sustainability
We scored the service as 2. The evidence showed some shortfalls. The service did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.
There was a clear framework of what must be discussed at a ward, team or directorate level in team meetings to ensure that essential information, such as learning from incidents was shared and discussed.
The service had contingency plans for emergencies – for example, a patient safety incident investigation policy was in place.
Staff had access to the equipment and information technology needed to do their work. The information technology infrastructure, including the telephone system, worked well and helped to improve the quality of care. Patients had access to internet services, a tablet and a computer located in the communal area.
The risk register did not include all risks for the ward that were present. We were therefore not assured that all risks were recorded and monitored appropriately, causing increased risk of avoidable harm to patients.
Staff undertook or participated in local clinical audits. The audits were mostly sufficient to provide assurance. However, the audit of the clinic room and medication storage area was at only 69% for compliancy in February 2026. The audit of patients taking S17 leave was at only 64% for January 2026. Staff had identified areas for improvement, but this had not yet had time to embed.
 

Partnerships and communities
We scored the service as 3. The evidence showed a good standard. The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.
Patients and staff could meet with members of the ward’s senior leadership team to give and receive feedback.
Staff worked well with partners and included them in discharge planning. We saw a social worker had completed a care needs assessment of a patient and had implemented a care package before the patient left the service.
 

Learning, improvement and innovation
We scored the service as 3. The evidence showed a good standard. The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contribute to safe, effective practice and research.
The service was introducing the Culture of Care programme. This nationwide initiative was designed to strengthen compassionate, safe and person-centred care across inpatient mental health services.