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

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

This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

Leaders had the skills, knowledge and experience to perform their roles. Staff knew and understood the provider’s vision and values and how they applied to the work of their team. Staff felt respected, supported and valued. Governance processes operated effectively. Performance and risk were managed well. Teams had access to the information they needed to provide safe and effective care. Staff collected analysed data about outcomes and performance. They used this to identify improvements.

This service scored 79 (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 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 knew and understood the provider’s vision and values and how they were applied in the work of their team. The trust’s senior leadership team had successfully communicated the provider’s vision and values to the frontline staff in this service.

Staff had the opportunity to contribute to discussions about the strategy for their service, especially where the service was changing.

Staff described the culture and psychological safety as good and were supported and valued in their team.

We heard managers and staff worked together to find solutions where there were difficulties, for example when talking to staff about people waiting for their first appointment with the memory services. However, we did hear concerns in some geographical areas there was a lack of psychology staff, but we did not hear any discussed solutions.

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. We spoke to many team managers over the course of this assessment and found them to be positive, resourceful and staff told us they felt supported by them. Staff told us they had positive leadership and supervision; there was a strong culture of promoting staff safety and wellbeing.

Leaders had a good understanding of the services they managed. They could explain clearly how the teams were working to provide high-quality care. Team leaders were knowledgeable, they worked in the local offices alongside staff, so they had a good working knowledge of the staff they managed and the difficulties they encountered on a day-to-day basis.

Leadership development opportunities were available, including opportunities for front line staff.

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.

People and carers had opportunities to give feedback on the service they received in a manner that reflected their individual needs. Feedback was gathered through friends and family responses, evaluation forms, workshops and training events.

Managers and staff had access to the feedback from people, carers and staff and used it to make improvements.

People and their carers were involved in decision-making about changes to the service. There were forums in place which they could attend and be part of across the trust for opportunities to do so.

Staff told us they were aware of the Trust's whistleblowing procedures and would feel able to use them without fear of victimisation.

Between June 2025 and June 2026, 26 Freedom to Speak Up (FTSU) concerns were raised across Mental Health Older People services relating to inappropriate attitudes, behaviour and relationships, bullying, work safety and wellbeing and bullying and harassment. Themes were discussed at executive level and reported to the People and Culture Committee and actions documented.

We scored the service as 3. The evidence showed a good standard. The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The trust had fully complied with the annual Workforce Race Equality Standard (WRES) and Workforce Disability Equality Standard (WDES) reporting requirements for 2025 – 2026. The trust had established a structured approach to supporting equality, diversity and inclusion through 7 staff-led networks and a developing Inclusion Advocates model. The 7 staff networks which were currently in place were Ability, Carers, LGBT+, Lived Experience: Mental Health, Neurodiversity, Race Equality and Cultural Heritage (REACH) and Women’s Network.

Staff and managers told us they were able to apply to work flexibly e.g. flexible working agreements to account for personal circumstances such as caring responsibilities and health issues. Managers put reasonable adjustments in place for staff members to help them carry out their role.

The provider undertook equality monitoring of staff within the service to ensure it was diverse in its make-up and representative of the people they worked with.

We scored the service as 3. The evidence showed a good standard. The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

Leaders held weekly group governance meetings which rotated the subjects: improving health, improving care, improving culture and improving value. Leaders held older person network meetings once a week. Staff enjoyed these opportunities to come together and share good practice and learning with each other.

The trust co-ordinated a Clinical Audit programme across all services. Between the older people community, crisis teams and memory assessment teams there were 9 audits that required completing, ranging from bimonthly to annually. The audit activity for the past 12 months June 2025 to June 2026 demonstrated a high compliance, 86% for all audits. However, overall compliance for annual physical health checks were 76% for June 2026. Managers told us of the quality improvement work on going to improve physical health checks.

The trust monitored high dose antipsychotic therapy. The trust’s clozapine policy included guidance for staff on monitoring of people during their therapy.

There was a clear framework of what must be discussed at team or directorate level in team meetings to ensure that essential information, such as learning from incidents and complaints, was shared and discussed.

Staff had implemented recommendations from reviews of deaths, incidents, complaints and safeguarding alerts at the service level.

Staff understood the arrangements for working with other teams, both within the provider and external, to meet the needs of people.

Staff maintained and had access to the risk register and could escalate concerns when required. Staff concerns matched those on the risk register. Waiting lists for the memory services were seen on the risk register and plans were in place for reducing these.

All services were seen to have business continuity plans had plans for emergencies, for example, loss of gas, water and electricity to buildings.

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. Staff had access to technology to record consultations and generate documentation for electronic patient records and outcome letters. Clinicians were exploring ways to maximise the benefits of technology.

Team managers had access to information to support them with their management role. This included information on the performance of the service, staffing and individuals’ care.

Information was in an accessible format, and was timely, accurate and identified areas for improvement.

We scored the service as 4. The evidence showed an exceptional standard. The service clearly understood and carried out their duty to collaborate and work in partnership, and services worked seamlessly for people.

Teams worked in collaboration with GP’s, care homes, social workers and staff told us of the many projects that were undertaken with external partners. There were trust wide agreements in place with GP practices and community staff taking bloods had developed stronger working relationships with medical colleagues. Staff told us emphasis was placed on collaborative working.

Services worked well with external partners. At the Memory Service for Central Norfolk in Norwich, Alzheimer’s society staff were based within the services and provided direct support to people and their carers after diagnosis. This was a pilot funded through Norfolk and was receiving good feedback.

Team managers told us how they attended the local neighbourhood network meeting and were working collaboratively with colleagues.

Older Persons community services in East Suffolk had received a RC Psych Accreditation for their services which reported their excellent partnership working including effective discharge planning with inpatient services, and strong links with voluntary organisations and social prescribing services.

Services worked with voluntary agencies including Suffolk Family carers, Anglia Care Trust, Active lives and Turning point. Staff told us how they had protected time to attend learning events and monthly meetings which allowed services to share information.

We scored the service as 4. The evidence showed an exceptional standard. The service had a strong focus on continuous learning, innovation and improvement across the organisation and local system. They always encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

We heard about the many innovations that were taking place in services, especially where the services had identified areas which required improvement. Family and carers were included in development of improvement initiatives through the working together group. Staff told us there was a strong commitment to improvement and service improvement and told us of the many projects they were involved with and awards they had achieved, including a trust award for innovation and service improvement within the Community Outreach team in Waveney and Great Yarmouth.

In Saxmundham a pilot was being established in the GP practice to focus on managing non-complex dementia presentations within primary care. This involved improving the assessment skills of primary care staff.

West Suffolk services received a high proportion of their referrals from care homes and the quality of the information received had a high impact on how quickly and safely services could respond. The service had commenced a pilot project to produce a set of tools and face to face education programme for care home staff starting with the 5 highest referring homes.

The Central Norfolk Memory service was working with the ICB innovation team and Newy Health on a digital memory support application which collected patient reported information and supported self-management. They also had dedicated research nurses on site and there was on-going involvement in dementia research and innovation projects.