Norfolk and Suffolk NHS Foundation Trust

On this page

• Overview
• Kindness, compassion and dignity
• Treating people as individuals
• Independence, choice and control
• Responding to people’s immediate needs
• Workforce wellbeing and enablement

At our last assessment we rated caring as good. At this assessment the rating has remained good.Staff treated people who used services with compassion and kindness. They respected the privacy and dignity of people. They understood the individual needs of people who used services and supported them to understand and manage their care, treatment or condition. Staff involved people who used services in care planning and risk assessment and actively sought their feedback on the quality of care provided. Staff informed and involved families and carers appropriately.

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.

The service always treated people with kindness, empathy and compassion and respected their privacy and dignity.

We spoke with 18 people who used services and 9 carers. Most people told us staff were respectful, polite and professional, and went above and beyond. We saw staff speaking with people and observed that they were treated with dignity, were listened too and that staff were friendly and understanding.

People told us that staff supported them with issues such as explaining the medication they were prescribed and also made referrals to other services such as food banks and the recovery college. We observed staff during a team meeting describe how they had assisted a person to obtain some food from a food bank and in care plans we saw that people were informed about medicines.

People told us their care was person centred, and they were pleased with the service and how they were treated. This included the timeliness of being referred for interventions such as physiotherapy, well-being groups and the recovery college. We saw in care plans that staff were linked in with other service provision for people including voluntary agencies and the recovery college.

Staff understood the individual needs of people who used services and identified individual needs as part of the care planning process.

The trust collected feedback from patients about their care. This included receiving feedback via the trust’s Friends and Family Test (FTT). The trust reported figures from October 2024 showed a 43% uplift in people responding in the first 10 months of 2024. At team level, people were also encouraged to give feedback via a patient reported experience measures which was recorded locally within teams.

The trust shared with us their NHS Community Mental Health Survey Benchmark Report 2023, which had a 23% response rate with 280 people completing the survey. The data from this survey showed that the trust is performing at a national average. The data however showed that while people who use services were receiving support during waiting times and in other areas of their lives, the trusts performance in this area was rated lower in this area compared to other trusts.

The service treated people as individuals and made sure people’s care, support and treatment met people’s needs and preferences. They took account of people’s strengths, abilities, aspirations, culture and unique backgrounds and protected characteristics.

Staff received training in recognising and responding to autistic people and people with a learning disability. Ninety-eight percent of staff had completed Learning Disability and Autism training.

The service made reasonable adjustments for people who used services. During the inspection, staff gave us examples of how they identified peoples’ individual needs. Staff told us, as part of the care planning process, they arranged an interpreter for an individual with hearing loss. Staff gave recent examples of arranging Mandarin and Turkish interpreters for people. We saw in care records that an individual’s neurodiversity needs were included as part of their assessment process. At 2 locations staff told us they had been completing autism assessments; however, it was not clear if this would be continued or expanded to other locations.

Staff gave information to people who used services to inform them of advocacy options available and ensured that people could obtain information on treatments, local services, rights and how to complain. Staff made adjustments for neurodivergent people including using communication cards. We saw information about advocacy services in the team base and the trust confirmed that people who used services could access various advocacy services.

Staff could signpost and share information with carers and young carers to a number of caring voluntary organisations as well as providing carers with an information booklet.

The trust involved experts by experience in a number of meetings including the Experience Advisory Group and City Anchorage Working Together Groups. These groups met regularly so that people who had used services could influence the way in which the trust delivered and improved services.

The trust shared data with us that showed they had completed a number of Quality Improvement (QI) projects where experts by experience and people who used services were part of the project work. People reported back how being involved in these projects had been beneficial into re-entering the workforce and provided a greater insight into the mental health care system. The trust had a 6-step carer process to ensure staff included carers where appropriate, which provided a therapeutic alliance between carers, people who used services and health professionals.

The service promoted people’s independence, so people knew their rights and had choice and control over their own care, treatment and wellbeing.

The teams we visited had peer support workers, who worked with people who used services to promote and support people’s independence and wellbeing by offering group and individual support.

The trust had dedicated carers’ leads supporting staff to ensure carers were provided with information about support services and their rights. The trust’s intranet had appropriate information for staff about supporting carers, including a carers directory. Carers we spoke with confirmed that the service encouraged people to make their own decisions and staff were helpful in promoting independence. They were positive about the impact of a recovery space group which was led by people who used services.

During our inspection, we reviewed care plans and the majority were holistic however the detail was missing in 7 out of 21 care plans and difficult to find using the patient records system. People’s voice, strengths and wishes were seen in care plans but this could be strengthened to give further depth and detail. Staff spoke of ‘My Recovery Plan’ (a care planning tool) and described how people who used services took the lead.

Psychologists told us that people who used services were central to formulating plans and deciding their goals, including deciding who else would be involved in their care.

We spoke with 18 people who used services, and they told us they were encouraged to be involved in planning their care and making decisions. Staff told us that the teams were linked into other local services such as recovery college and employability and people confirmed that they had been referred to services which helped them maintain their independence.

The service listened to and understood people’s needs, views and wishes. Staff responded to people’s needs in the moment and acted to minimise any discomfort, concern or distress.

The trust operated under their own “Clinical Harm Review Standard Operating Procedure” which was in place to identify any harm which may have arisen because of a delay in waiting for assessment and or treatment. This procedure identified themes so that lessons could be learnt. Staff told us the management of caseloads had been improved and there was a timeframe for cases and if the timeframe was missed this was classed as a breach. Managers and staff told us caseloads were monitored every week locally.

The trust shared the average wait in days from first attended assessment to first attended treatment for February 2025 was 5.25 days. Each person had a safety plan and was given a red, amber or green prioritisation category. People who were prioritised as red (the highest risk category) were contacted every week and discussed in daily huddles. Individuals waiting for their first 72-hour assessment were given crisis contact numbers to call, including the duty number, NHS 111, and voluntary organisations.

Staff identified and responded to changing risks to or posed by people who used services. We saw risk assessments and safety plans were updated when there was a change in people’s presentation, risk or levels of distress.Staff told us that if people who used services were not engaging, there was a process to follow to ensure their safety. Staff would explore all options, which included encouraging engagement, or providing transport to the office if accessing the physical location of the service was a barrier.

People who used services told us they received regular contact especially where there was a risk of self-harm and 1 person told us, “I don’t think I’d be here if it wasn’t for the phone calls”. Carers told us the services were responsive and there was life-saving treatment.

The service cared about and promoted the wellbeing of their staff and supported and enabled staff to always deliver person-centred care.

Staff spoke very positively about their managers and colleagues, they felt respected, supported and valued. They said they were proud to work for the trust and their team.

Staff had personal alarms and there were office alarms in all the interview rooms and there was a text back system to check everyone was safe after visits or a check in board. Staff told us leaders were more accessible than before, and team members now had a greater range of experience and backgrounds which had changed the culture and learning from each other.

Staff had access to support for their own physical and emotional health needs, access to reflective and informal supervision and Trama Risk Management (TRIM). A social worker described how they had attended a forum for social workers for their well-being. Staff could access peer support from trained champions. The service had champions in areas such as wellbeing, veteran support, menstrual health and menopause support. There was a staff support and occupational health service which also offered support to staff for their physical and emotional needs.

Managers provided new staff with appropriate induction. Managers provided staff with supervision and appraisal of their work performance. The percentage of staff that had had an appraisal in the last 12 months was 94%. The percentage of staff that received regular supervision was 97%. Managers ensured that staff had access to regular team meetings. Some teams held face-to-face team meetings which connected staff together very well. There was a vacant post of a service manager in Kings Lynn which meant that team meetings at a service level were not able to be provided at the time of this assessment.

Managers supported staff to develop and gave them an annual appraisal of their work. Appraisals also showed compliance against trust targets and ranged between 85% and 100% across all teams. Staff told us that they had also received clinical supervision and group supervision and were very well supported by their teams and their managers.

However, the service’s staff sickness and absence across the 16 teams averaged 6.16% which was over the target 4.91%. In 9 out of the 16 teams staff sickness rates were above the target. Managers told us there was ongoing recruitment and the trust had made changes to the recruitment and review of sickness procedures.