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

At our last assessment we rated this key question good. At this assessment the rating has remained as good. This meant people were safe and protected from avoidable harm.

Staff assessed and managed risks to people and themselves well. Staff understood how to protect people from abuse and the service worked well with other agencies to do so. The service used systems and processes to safely prescribe, administer, record and store medicines. The service managed safety incidents well.

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 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.

The services reported a total of 640 incidents and no never events from June 2025 to June 2026. The 3 most significant incidents were due to death by natural causes or an unconfirmed cause of death and concerns of abuse. Leaders told us that all incidents were reported on the Datix system, 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.

There was evidence that changes had been made as a result of feedback. Leaders gave us examples of learning from incidents and described how they used after action reviews, as a method of evaluation of outcomes of an activity or event. This was a facilitated discussion that included learning and improvements for the future. For example, a clinician reflected on an incident and the learning that was identified when a prescription pad was lost, to carry fewer prescription sheets and ensure pads were securely stored when not in use.

The service reported there had been no Prevention of Future Deaths reports in relation to the Older Persons Community Teams since 2020. Each quarter the trust leaders held a focused learning from deaths meeting, the main themes were data, improvement actions and learning outcomes and recommendations. The trust reported 5 patient safety events where duty of candour was applied.

All staff knew what incidents to report and how to report them. Staff reported all incidents they should report. Staff understood the duty of candour. They were open and transparent and gave people and families a full explanation when things went wrong. Staff received feedback from investigation of incidents, both internal and external to the service.

Staff met to discuss feedback, staff told us this happens in safety huddles, MDT, team and business meetings. Staff told us there were lots of opportunities to have away days or learning and complex monthly case reviews.

Staff were debriefed and received support after a serious incident. Leaders shared minutes of meetings that demonstrated that risks were discussed regularly. Agenda items included review of outstanding safety actions, rapid response huddles and patient safety alerts.

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 person was received to determine if the individual’s need could safely be met. Referrals generally came from people’s GP’s through to the service’s access team, screened by the duty worker and if accepted referred to the weekly MDT triage meeting who reviewed referrals. Complex cases would be discussed further by smaller teams.

Leaders shared weekly management meetings for the older people’s pathway, agenda items included discussion of risks, shared learning and any alerts or assurances. We saw evidence that the trust monitored actions through action logs and progress updates.

Staff involved all the necessary healthcare and social care services to ensure patients had continuity of safe care, both within the service and post-discharge. Staff in community teams told us they had good relationships with social care colleagues who attended their MDT meetings every week and they had daily flow meetings between the community teams and the wards.

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 trust demonstrated they held an up-to-date safeguarding policy for adults and children. The trust held quarterly safeguarding and public protection meetings which included locality representatives, Integrated Care Board (ICB) safeguarding colleagues, as well as attending the Norfolk and Suffolk Safeguarding Board meetings.

The service monitored safeguarding cases. Data received from Datix indicated 22 safeguarding referrals were made during April to June 2026. The most common concern was domestic abuse where 1 party had dementia or other care needs.

Staff were knowledgeable about safeguarding processes and escalation pathways. Staff were trained in safeguarding, they demonstrated how they recognised safeguarding as a key priority and had raised safeguarding concerns appropriately. All staff were required to complete mandatory training in safeguarding. For level 1 safeguarding adults and children training, current compliance rates showed that 100% of staff had completed this with 95% of staff completing level 3 safeguarding adults. For level 1 safeguarding children training 100% of staff completed this, 98% of staff completed level 2 safeguarding children training. While 94% of medical staff completed level 3 safeguarding children training.

Staff told us they received safeguarding supervision every 6 months which was an online meeting with the safeguarding team where staff could discuss cases. Staff told us they could discuss cases in clinical and regular supervision and in their morning safety huddles.

Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies such as the multi-agency safeguarding hub (MASH), care homes, GP’s and social care staff.

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 people and themselves well. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The trust completed audits of risk assessments and risk management plans across all services. The overall compliance level between February 2026 to April 2026 was above 90%, audit outcomes were reviewed at weekly locality meetings, shared with teams and monitored through action plans. The trust had a clinical risk assessment and management policy and staff received formulation training and risk assessment and safety planning training to perform their required roles.

We reviewed 22 patients care records, including their risk assessments and risk management plans during the assessment. Staff carried out an initial risk assessment using a recognised tool and reviewed these regularly, including following any incident. Staff were aware of individual risks and took appropriate action to prevent or reduce harm.

The trust reported that there had been no recorded incidents of restrictive practice in the last 6 months, from January to June 2026.

Staff involved people in their care planning and risk assessments. Staff told us they supported people to make independent choices wherever possible. Staff communicated with people, so they understood their care and treatment, including finding effective ways to communicate with people with communication difficulties. Staff told us they were able to provide easy read care plans. People and carers told us behaviour monitoring plans and risk assessments were reviewed regularly.

During observation visits we saw staff actively listened to people and gave them sufficient time to express their views and communicated calmly and sensitively. Records demonstrated that people were involved in discussions and decisions about their care and treatment wherever possible.

Staff enabled people to give feedback on the service. Staff told us they were able to source advocacy for people.

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.

The trust had a site-specific risk assessment and safer premise plan for each location. A safer premise plan was given to all staff at the location which included a ligature risk assessment and floor plan.

We reviewed the environments of Wymondham and Newmarket offices which were clean and well furnished. There were many useful leaflets including Age UK, patient and carer feedback forms, carers advocacy advice, rural transport, patient advocacy service, suggestions complaints and compliments, telecare services and the recovery service. Waiting rooms had sufficient chairs for people to sit.

Wymondham had shared office space which several teams used including talking therapy and social care staff. There was a water cooler and toilets. The area had level access and automatic doors at the entrance. There was designated parking at the front of the building. The clinic rooms were air conditioned, and staff used two-way radios. Fire extinguishers had been serviced. There was an automatic defibrillator, first aid and ligature cutters available for staff nearby to the reception area in case of emergencies. However, clinic rooms lacked decorative features such as pictures or artwork , which may have reduced the overall comfort and welcoming feel of the environment for people attending clinics.

In the Newmarket offices, staff used two-way radios in the clinic rooms. Staff told us equipment in the clinic rooms was calibrated every year and was completed 3 weeks ago. There were emergency pull cords in the clinical rooms and managers told us the rooms had good sound proofing. There was no air conditioning but fans for use in hot weather. There was a separate notice board for the older person community service. The reception area was level access; there were automated doors and a disabled car park nearby.

However, staff told us sometimes it was difficult to get rooms as they shared with other teams. The rooms had blinds and curtains but there were no pictures, so lacked a welcoming environment.

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

At the time of inspection the service’s full establishment of staff was 291 staff with 286 of these posts filled (98%). For the period July 2025 to June 2026 there was no agency use and 41 shifts by bank staff. The annual staff turnover target was 10% and the service had an annual turnover rate of 6.69% between August 2025 to July 2026, which meant turnover was within target. Staff told us retention was very good, with very few staff leaving and staff told us they loved their jobs. However, the trusts target for sickness was 4.9% the overall sickness rate for all services between August 2025 and July 2026 was 6.2% which was higher than the trust target.

Staff had completed and were generally up to date with mandatory training. The trust’s target compliance level was 85% for mandatory training. The data shows all subjects have good compliance levels. Where individual teams had compliance below 85% leaders told us action plans were in place to progress individual staff within 1 month.

Overall, all teams achieved compliance of 85% for most mandatory training. The only exception to this was Oliver McGowan part 2 training, which had a compliance rate of 65% for clinical staff and 70% for non-clinical staff. The leaders told us the training was recently introduced in late 2025 and the service aimed to reach their 85% target in 2027.

Staff had all received appropriate training for their respective roles. Staff told us there was a commitment to ongoing training and professional development and they had excellent learning opportunities. Staff told us they received operational supervision and clinical supervision.

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.

The trust had an up-to-date Invention Prevention and Control Manual for guidance for staff.

Staff maintained equipment well and kept it clean. All patient areas and clinics were clean, had good furnishings and were well-maintained.

Cleaning records were up to date and demonstrated that the buildings were cleaned regularly. Staff training compliance for infection prevention and control level 1 was 99% and level 2 was 100%.

We scored the service as 3. The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

The trust had a comprehensive management of medicines Policy which provided the overarching framework for the safe prescribing, supply, storage, administration, monitoring and disposal of medicines across community services.

Between January and June 2026 there had been 22 medication-related incidents, all incidents were recorded as resulting in no harm. Common contributory factors included communication failures, documentation inaccuracies, care transition issues, medicines storage and access concerns, and administration errors by carers or external providers. A common theme was the interface between organisations such as care homes, acute hospitals and GP practices, rather than 1 team.

We reviewed minutes of the medicine’s optimisation group from April to June 2026, the group had begun by identifying risks and were moving towards implementing structured improvement programmes. Staff completed bi monthly audits of the community teams' clinic rooms and medicines storage areas.

Staff followed good practice in medicines management. We reviewed the medication room at the Sage Centre Newmarket. The medication room was well organised, secure and appropriately maintained. Staff demonstrated an understanding of their responsibilities in relation to medicines management and there were systems in place to support the safe storage, administration and monitoring of medicines. Medication storage cupboards were organised in a way that reduced the risk of selection errors. Arrangements were in place to separate different types of medication where appropriate. Staff described processes for checking medication stock and identifying medicines approaching their expiry dates.

The service had arrangements in place for the safe storage and administration of depot medication. Staff administering depot injections were appropriately trained and understood the importance of checking prescriptions, confirming the identity of the person receiving the medication and accurately recording administration.

There were systems for monitoring when depot injections were due and following up with people.

However, fridge temperatures were not always monitored and recorded with gaps in the months of July and June 2026 without explanation. We inspected the clinic room in Newmarket and found the environment to be clean, tidy and appropriately maintained.

A concern was identified regarding the height of the examination bed. The bed was considered too high and was not adjustable, which could present difficulties for older people, particularly those with reduced mobility, frailty or an increased risk of falls. However, leaders sourced a height- adjustable bed and loaned to the site within a week, to support people with frailty and mobility needs and a phlebotomy chair was then purchased, which provided a more suitable and sustainable solution.

Staff reviewed the effects of medication on people’s physical health and in line with National Institute for Health and Care Excellence (NICE) guidance, especially when the person was prescribed a high dose of antipsychotic medication. Staff told us clozapine monitoring remained the responsibility of secondary care and each locality had a Clozapine Clinic to provide for this service.

Staff told us they monitored blood pressure and diabetes when people were taking anti-psychotic drugs. Staff were knowledgeable when we spoke to them about initiation and monitoring of medicines, their effectiveness and possible side effects.

Records included information about prescribed medicines, their effectiveness and any identified concerns or side effects. Where appropriate, staff liaised with prescribers, GPs and other healthcare professionals to support safe medicines management.

There was mandatory training for clinical staff in medicines management which included medicines management, administration of medicines, medicines optimisation, controlled drugs and safe handling of medicines. Compliance with this training was 96%.