Norfolk and Suffolk NHS Foundation Trust

On this page

• 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 as good. At this assessment the rating has remained good. This meant people’s outcomes were consistently good, and people’s feedback confirmed this.

Staff developed individual care plans which were reviewed regularly through multidisciplinary discussion and updated as needed. Staff provided a range of treatment and care for people based on national guidance and best practice. The team included or had access to the full range of specialists required to meet the needs of people. Staff from different disciplines worked together as a team.

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.

We scored the service as 3. The evidence showed a good standard. The service made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

Staff completed a comprehensive mental health assessment of the person in a timely manner once accepted into the service. Staff in community teams described how they carried out their first assessment of people’s needs which included a review of historic GP and social care records and a post assessment for people after leaving hospital.

Staff told us long term physical health conditions were monitored by the individuals’ GP, but community clinicians provided supportive monitoring, identified physical health needs in care plans, and provided support and encouragement to attend appointments.

Managers from the memory services described how they completed detailed assessments as part of their diagnosis service. Physical and neurological causes were considered and ruled out before giving a diagnosis of dementia.

Overall, the care records reviewed provided positive evidence that people received safe, effective and person-centred care. Records were generally comprehensive, up to date and reflected patients’ individual needs, preferences and circumstances.

We reviewed 6 records in the community older people teams Bury North, 7 records in the Wymondham team, 5 records in the Intensive Older People’s service (IOPS) in central Norwich and 3 records in IOPS Team for Great Yarmouth and Waveney.

Care records contained detailed assessments which considered peoples’ mental health, physical health, social circumstances and identified risks. There was evidence that staff took a holistic approach to assessment and considered the wider factors that could affect people’s health, wellbeing and independence.

Care plans were personalised, holistic and recovery oriented. Staff updated care plans when necessary.

We scored the service as 4. The evidence showed an exceptional standard. The service always 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. They worked to develop evidence-based good practice and standards. Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Health Act Code of Practice and discharged these well.

Staff provided a range of care and treatment interventions suitable for people. The interventions were those recommended by, and were delivered in line with, guidance from the National Institute for Health and Care Excellence. These included medication and psychological therapies activities. Staff were trained in and had a good understanding of the Mental Health Act, the Code of Practice, and the guiding principles.

The teams included, or had access to, the full range of specialists required to meet the needs of people using the service, including doctors, nurses, occupational therapists, clinical psychologists and social workers. The service assessed and treated both organic and functional mental health conditions.

Staff ensured that people had access to physical healthcare, including access to specialists when needed. We were told of good practice initiatives taking place in Suffolk where they had recently set up physical health clinics.

The multidisciplinary team offered a range of therapeutic interventions. Psychologists delivered psychological therapies including cognitive behaviour, eye movement desensitisation and reprocessing, advanced dementia care approaches, compassion focused, behaviour family and acceptance and commitment. Interventions included non-pharmacological interventions as well including environment adaptions, carer support and education, social care support and care packages and signposting to other services.

Staff participated in clinical audit, benchmarking and quality improvement initiatives. Staff told us of many examples of quality improvement initiatives they were working on or recently completed including the West Suffolk Older Person Dementia Intensive Support Team pilot which had standardised how care home and GP services can refer into the service and a cross- system Dementia Oversight Group were joining up services with primary care, the acute hospital, social care and the voluntary sector with a direct referral pathway.

East Suffolk teams and the Waveney Memory Treatment Service shared with us their excellent feedback they had received from their recently accredited services with the Royal College of Psychiatrists for Community Mental Health Services (ACMHS) programme and the Memory Services National Accreditation Programme (MSNAP).

The Sophie Centre Memory Service in Norwich shared the quality improvement work they had been involved with to work towards reducing waiting times for their diagnosis and treatment service. This involved setting up a one stop shop for dementia patients whereby diagnosis and treatment would take place all in the 1 visit.

The Central Norfolk Intensive Older Person Service had redesigned the triage screening tool to create a more structured, consistent and comprehensive approach to the assessment of all referrals entering the service.

Staff were experienced and qualified and had the right skills and knowledge to meet the needs of the people. Managers provided new staff with appropriate induction.

Managers provided staff with supervision and appraisal of their work performance. Managers ensured that staff had access to regular team meetings. Staff told us that they attended regular team meetings and supervision including clinical supervision. The clinical supervision trust target was 85%, with staff achieving 90% at the time of inspection.

The percentage of staff that had had an appraisal in the last 12 months was 95%.

Managers identified the learning needs of staff and provided them with opportunities to develop their skills and knowledge. Managers ensured that staff received the necessary specialist training for their roles.

We scored the service as 3. The evidence showed a good standard. The service 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.

Staff held regular and effective multidisciplinary team (MDT) meetings and social workers from social care attended which staff found was very supportive. Staff were able to discuss complex cases together for support and give feedback from carers or individuals. Each service operated their own MDT meetings. Doctors and psychologists told us they also held their own separate meetings. Managers told us there was strong MDT working and consultant collaboration.

Community staff shared information about people at daily safety huddles, staff were able to discuss who was on duty that day, any concerns about individuals and an opportunity to check each other’s wellbeing.

The teams had effective working relationships with other relevant teams within the trust. There were daily flow meetings which all the community teams and wards attended to ensure people transitioning from hospital into the community had their needs met. The teams had effective working relationships with teams outside the organisation. Staff told us they had good relationships with the integrated neighbour teams and participated in their weekly meetings. The teams worked closely with GP’s, adult community mental health teams, social workers, care homes, voluntary and statutory agencies.

We scored the service as 3. The evidence showed a good standard. The service supported people to manage their health and wellbeing to maximise their independence, choice and control. The service supported people to live healthier lives and where possible, reduced their future needs for care and support.

Staff supported people to live healthier lives. Staff told us they gave information to people that included physical health and how to age well. Community nurses, as part of their assessments, included an assessment of healthy eating and drinking and provided advice and support.

Managers from the memory service in Norwich told us post diagnosis, people were linked into community groups, for example theatre groups, dementia friendly football groups and an 8-week programme living well with dementia group, which was very popular. The occupational therapy team provided reviews of daily living and support maintaining independence.

Community teams told us about groups they ran, for example ‘tree of life’ for people living with bipolar disorder, which enabled people to come together to explore their journey. Staff signposted people to the recovery college, peer support opportunities and community-based dementia support services.

Managers told us there was a physical health team within the trust and physical health audits which were completed for people on the severe mental health register. Community nurses had physical health grab bags to carry out physical observations while on their visits including blood pressure machine and weighing scales. Staff told us however that equipment was limited but this was being addressed by the trust. More physical health projects were being developed to strengthen the physical health assessments being carried out. Staff told us physical health concerns, if identified, were escalated appropriately to primary care colleagues.

Staff told us about the Thetford Healthy Living Centre which brought together numerous health services including community services for older people in a 1 stop shop.

We scored the service as 3. The evidence showed a good standard. The service 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 used recognised rating scales to assess and record severity and outcomes. The trust benchmarked themselves nationally and findings indicated that older person’s services were performing above the national average for outcome measure collection.

Outcomes were overall higher than when people were admitted to the service, there were some high performing teams where all outcome areas were positive and some examples where some areas of outcomes were seen to be lower, for example leisure, friendships and relationships.

Staff used technology to support people effectively. Staff told us they had created a spreadsheet to record people who were taking anti-psychotic medicines to ensure they were being monitored correctly.

We scored the service as 3. The evidence showed a good standard. The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

When people lacked capacity, staff made decisions in their best interests, recognising the importance of the person’s wishes, feelings, culture and history. Staff took all practical steps to enable people to make their own decisions. Staff told us people’s capacity was assessed at every assessment, and they discussed all options with people and chose the least restrictive option. Best interest meetings took place if a person did not have capacity. Staff placed significant emphasis on capacity in older people and encouraged people to make independent choices and interact in society.

For people who might have impaired mental capacity, staff assessed and recorded capacity to consent appropriately. They did this on a decision-specific basis about significant decisions.

The service informed people of their rights relating to consent and treatment and respected these when delivering person-centred care and treatment. The records demonstrated that staff considered peoples’ mental capacity and ability to participate in decisions about their care and treatment. Where relevant, consideration was given to the principles of the Mental Capacity Act and the involvement of relatives, carers or other representatives.

The trust had a Mental Capacity Act policy in place, and 93% of staff were up to date with Mental Capacity Act and Deprivation of Liberty Safeguards training.