Norfolk and Suffolk NHS Foundation Trust

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• 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 service met people’s needs.

At our last assessment we rated this key question good. At this assessment the rating has remained as good.

Staff supported people with activities outside the service, such as voluntary groups and family relationships. The service met the needs of all people including those with a protected characteristic. Staff helped people with communication, advocacy and cultural and spiritual support. The service treated concerns and complaints seriously, investigated them and learned lessons from the result.

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 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 observed staff giving care in people’s individual homes. The interactions demonstrated a person-centred approach and a good understanding of people’s individual needs. We observed active listening by clinical staff and genuine interest in their experiences of taking their medicines.

Staff explored how individuals were managing their treatment, whether they had experienced any side effects from medication and whether they had any concerns. The nurse acknowledged people’s views and responded to questions in a reassuring and professional manner.

Staff demonstrated a strongly empathic and person-centred approach and took sufficient time to listen to patients, understand their individual experiences and respond appropriately to their needs.

Care records we examined demonstrated that staff had developed a good understanding of the people they supported, including their individual circumstances, preferences and support networks.

We scored the service as 3. The evidence showed a good standard. The service understood the diverse health and care needs of people and their local communities, so care was joined-up, flexible and supported choice and continuity.

The trust’s equality impact assessments policy outlined that all trust policy documents must be equality impact assessed ensuring equality considerations were built into policy development from the outset. These included health inequalities reflecting the trust’s responsibilities, not only to consider protected characteristics under the Equality Act, but also to assess impacts on groups experiencing health inequalities, such as carers, homeless people, people with addictions, refugees, those living in deprived areas, and others who may face barriers to healthcare.

Staff provided people and their carers with information and advice on the range of support services and community networks available within the localities where they lived. This included voluntary and trust led working together groups. These services provided practical information, peer support, and community-based opportunities to help individuals maintain their wellbeing and quality of life.

People and carer involvement group meetings provided a space for people to share experiences, provide feedback and discuss and influence service development.

Staff supported people to maintain contact with their families and carers. Staff told us family were involved if people consented to this and they were invited to attend any meetings concerning their family member. A carers council provided feedback and helped shape future developments. The trust provided carer support through a network of staff carer ambassadors.

We scored the service as 3. The evidence showed a good standard. The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

Staff made notifications to external bodies as needed. Information governance systems included confidentiality of people’s records. The service complied with the Accessible Information Standard.

Staff ensured that people could obtain information on treatments, local services, rights, and how to complain. The information provided was in a format accessible to the person. The carer working together group had a quality improvement project reviewing documents to ensure they were easy read.

Staff told us information leaflets could be made available in various languages spoken by people. Staff directed carers to Suffolk family carers for support and provided carers packs.

Staff ensured carers, families and commissioners were regularly updated about people’s progress. We observed 2 outpatient appointments, where dementia was diagnosed. The service provided information, advice, treatment in line with National Institute for Health and Care Excellence (NICE) guidance, signposting to other organisations and individual follow-up and review. The service also recognised the importance of involving and supporting relatives and carers. This included information, advice, carer support groups and referral for a Carer’s Assessment. Memory treatment nurses told us how they provided information and education about dementia post diagnosis.

At the central Norfolk memory service, an online information session was provided to people post dementia diagnosis. This focussed on improving people’s experience to have a better life.

We scored the service as 3. The evidence showed a good standard. The service made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. They involved people in decisions about their care and told them what had changed as a result.

There had been 30 complaints in the last 12 months from June 2025 to June 2026 with 12 of these upheld. There had been no complaints referred to the Ombudsman in the last 12 months.

Themes from these complaints had been collated and 8 complaints upheld were to do with medications prescribed incorrectly or side effects and 4 complaints upheld were from a lack of an empathetic approach from staff.

There had been many compliments to the teams from June 2025 to June 2026. There had been 93 compliments from carers, 78 from people who used the services and 10 from external organisations.

People knew how to complain or raise concerns. Contact details were given on discharge letters and information was available on how to complain in reception areas.

Staff knew how to handle complaints appropriately and discussed compliments and complaints as part of their team meetings. If people wished to give feedback on the service, there was a feedback form for friends and family. Staff told us if they did receive complaints they would discuss them in team meetings and learn from what went wrong.

Staff received feedback on complaints and acted on the findings. Staff told us that following a person’s suggestion that there were not enough groups, a new group called ‘the tree of life’ was established. This group brought people with bipolar disorder together to explore their journey.

2. We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure that people could access the care, support and treatment they needed when they needed it.

The memory assessment teams targets was to see people for their first assessment within 6 weeks (42 days). The service was not achieving their targets in June 2026, with wait times ranging between 47.5 to 194 days between teams. However, managers told us of the significant work and projects that were underway to reduce these wait times. Staff told us that people were fast tracked, if they had early onset dementia or another risk factor when they needed an earlier diagnosis.

The trust had an access and waiting list policy to ensure people received timely, equitable and clinically appropriate access to care.

The older people’s community mental health teams held a target to see people for an initial assessment within 28 days. Of the 11 teams in June 2026 all but 2 teams had achieved this target, the other 2 teams had achieved 35.8 days and 30 days.

Older person crisis teams were providing a very responsive service from referral to assessment. In June 2026, wait days were between 0.3 and 3.1 days.

The timeframe from assessment to treatment for June 2026 showed that most teams commenced treatment on the same day as assessment or within 1 day. There was only 1 team who took longer, taking 4.6 days to commence treatment.

Occupational therapy was well provided across all the services with little waiting time for people.

There were significant differences in wait times for psychology depending on where in the locality you were accessing this service. In June 2026, this ranged from no waiting time in Bury South to an average wait time for psychological therapy in North Norfolk as 16 weeks.

We scored the service as 3. The evidence showed a good standard. Staff and leaders actively listened to information about people who were most likely to experience inequality in experience or outcomes and tailored their care, support and treatment in response to this.

The service sought and responded to feedback from people who were more likely to experience health inequalities, adapting care and support to meet their individual needs.

Equality impact assessments were undertaken to ensure policies and procedures promoted equality and did not disadvantage people with protected characteristics.

Staff within the service and the wider organisation promoted a culture in which the people using the service felt empowered to give their views.

Almost all staff had completed mandatory equality, diversity, inclusion and human rights training with a compliance rate of 98%.

We scored the service as 3. The evidence showed a good standard. 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 supported people to make decisions about their care, treatment and their future.Staff created personalised care plans to account for people’s needs, wishes and feelings. Records demonstrated that people were involved in discussions and decisions about their future care and treatment wherever possible. Where appropriate, relatives and carers were also involved, with consideration given to people’s consent, wishes and preferences.

Staff ensured all relevant healthcare professionals and other relevant bodies were involved in planning the care and treatment of people with complex needs. There was positive evidence of multidisciplinary working. Records demonstrated communication and information sharing between nurses, psychiatrists, occupational therapists, GPs, social care professionals and other relevant services. This supported continuity of care and enabled people’s changing future needs to be considered and responded to appropriately.