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

At our last assessment we rated effective as good. At this assessment the rating has stayed the same as good.

Staff assessed the physical and mental health of all people who used services on admission. They 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 who used services based on national guidance and best practice. The team included or had access to the full range of specialists required and staff from different disciplines worked together as a team to meet the needs of people who used services. Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Health Act Code of Practice and discharged these well.

This service scored 71 (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 did not always have clear and easily accessible plans for all people, including risk, discharge, physical health, and crisis and recovery in their electronic record. However, the service made sure people’s care and treatment was effective by assessing and reviewing their health, care, well being and communication needs with them.

We looked at 21 care records across the community mental health teams (CMHTs) and the early intervention teams. Staff completed a comprehensive assessment for people referred to the service in a timely manner. We observed an initial assessment meeting in Kings Lynn and a referral meeting in Great Yarmouth. Referrals were received via the access and assessment team and we saw that all referrals were discussed in detail including reviewing GP records, medication and previous engagement with mental health services.

The quality-of-care plans varied across the teams. We found 7 off the 8 care plans completed in the early intervention teams were of a good quality and were recorded in the correct area of the trust’s electronic records system. Within the CHMT teams, we saw variation in completeness of care plans, in Suffolk 6 off the 7 care plans we looked at were good quality, however in Norfolk 5 of the 6 care plans had some missing information and staff told us they did not have adequate time to ensure these care plans were always completed. Where information was missing, we found 4 care plans did not have crisis plans, 2 care plans had no discharge planning,1 care plan had no physical health checks and 1 was out of date. In 3 care plans we reviewed, 1 recovery plan was not up to date, 1 not complete and 1 partially complete. One risk assessment was not up to date and 1 was not detailed enough. This meant that some people did not have clear and easily accessible plans for discharge, physical health, and crisis and recovery in their electronic record.

Staff we spoke with also said that the trust’s electronic record system, was not efficient to use and therefore updates and reviews of care plans and assessments were stored in daily progress notes rather than the correct section of the records.

When care plans were completed well, we saw that risk assessments were person centred and the individual’s voice was clearly included, there was evidence of joint working with other agencies. Discharge plans, safety plans and recovery plans were all in place, the care plan was clear, the crisis plan listed emergency numbers to contact and physical health monitoring and outcome monitoring was completed. However, there was inconsistency in the records we reviewed.

Staff used an outcome tool which used person centred questions and was able to demonstrate how people who used services wanted their care to be delivered. The trust provided data which evidenced people found this tool helpful, as they were able to look back and reflect on their progress.

The service 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 and current 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 the people who used community mental health services. There were a range of treatments available to people who used the community mental health teams including mental health nursing, psychiatry and social work. In good care plans, we saw treatments and interventions available to help people manage symptoms and recovery included medication, family support, physical health monitoring and access to a recovery college. Psychological treatments and interventions were also available including cognitive behaviour therapy (CBT), acceptance and commitment therapy (ACT), and eye movement desensitisation and reprocessing therapy (EMDR). There remained a small number of people on a waiting list for psychological therapy (36 people in March 2025).

Staff told us that people referred to the services, received a phone call from the service within 4 weeks of being placed on the waiting list, so that individuals had information about the treatments they were waiting for. People who used services told us they received physical health care checks, and the trust provided us with data to show that 11 teams had improved their score in the physical health audit in last quarter December 2024 to March 2025 to 79.8% however this was just below the trusts compliance rate of 80%.

We saw the trust had quality improvement initiatives on going with project teams including local staff participation. These included a quality improvement project for CHMT teams to develop clear treatment pathways for people who used services at the beginning of their treatment.

The team included or had access to a full range of specialists required to meet the needs of people who used services. There were a range of staff in services including doctors, nurses, clinical psychologists, social workers and peer support workers. We did not meet any occupational therapists during our visits. Staff explained that these skills were often assessed by linking into other teams. However, trust data showed that teams did employ occupational therapies. Staff were experienced and qualified and had the right skills and knowledge to meet the needs of the people who used services.

Managers identified the learning needs of staff and provided them with opportunities to develop their skills and knowledge. Staff told us there was opportunities for specialist training but not as much as previously and the budgets were managed centrally and access to this training was not consistently available at every team we visited. Carers told us that people who used services had helpful appointments with staff and were offered a range of treatments. They told us care and treatment including medicines were clearly explained during appointments.

People who used services felt they were given personalised treatments and therapies, particularly psychological therapies. However, 1 individual told us psychiatrists should take a more holistic approach as they felt they needed more support than medication alone.

Staff received training in the Mental Health Act in line with the responsibilities of their role. At the time of inspection, the compliance rate was 97.75%

The trust had 172 people who used services on a Community Treatment Order (CTO). The Mental Health compliance team monitored when people on a CTO were due to have their Section 132 rights read to them. The team sent reminders to staff to make sure people had their rights read to them when this was due.We saw the trust had a Community Treatment Orders policy which set out the legislation and best practice to ensure compliance with the Mental health Act in relation to Community Treatment Orders.

Staff had easy access to administrative support and legal advice on the implementation of the Mental Health Act and its Code of Practice. Staff knew who their Mental Health Act administrators were and had easy access to local Mental Health Act policies and procedures. Staff told us they gave people who used services information about independent mental health advocacy.

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.

Safety huddles took place every day across all teams and staff worked collaboratively, with the ability to escalate any risks. The trust provided evidence of weekly MDT meetings across all teams, which included a mixture of staff from all disciplines. For people who used services there was a plan to document what action took place. Staff told us that carers could attend MDT meetings.

Staff told us they found managers open and supportive and they enjoyed working in their teams. Colleagues told us their team members were helpful, open and caring, and that the culture of their team was safe and supportive. Team members told us they felt supported and listened too, and they felt able to challenge and escalate risks.

The teams had effective working relationships, including good handovers, with other relevant teams within the organisation, including the crisis teams. However, staff told us the staff from the acute wards did not always communicate well and did not always follow the agreed discharge plan.

The NHS Model Hospital benchmarking data showed that follow-up contact after discharge from acute care consistently exceeded the national safety standard of 72 hours, supporting safe transitions into the community.

The teams had effective working relationships with teams outside the organisation.

We saw examples of good practice happening across the teams working with other agencies including carrying out joint assessments. There was evidence of regular contact with social care, the police and employability services.

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 who used services to live healthier lives. Staff were able to share examples with us of encouraging people to take exercise and improve sleeping behaviours. Staff collaborated with other professionals, such as occupational health therapists from external teams, to share information on healthy living and with dieticians to provide guidance on for healthy eating. We saw that teams were regularly recording information such as people’s weight.

Staff spoke of risk assessments and safety plan’s and described how people in their services were fully involved, collaborated with and chose with whom they wished to share their safety plan. Staff told us they used open ended questions to encourage people to come up with their own solutions and people who use services as being central to risk assessment and care planning.

People who needed support were offered support workers who helped with daily tasks such as cleaning their homes and looking after pets.

Staff told us they used a recovery outcome model to assess better eating, sleep, community connections, friendships, and relationships. Staff told us this tool increases peoples’ confidence and to advocate for themselves.

Some of the teams had physical health nurses, part of their role was to encourage people who used services to live healthier lifestyles.

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.

The community teams were using a measure to monitor the outcomes of the people who used services. The trust measured the impact of care via this method and shared the information with teams. The outcomes measured included accommodation and employment, physical and mental health, medication, safety and relationships. There was on-going monitoring of the outcome tools by the trust each month by individual teams and there had been recognition that there is opportunity for improvement. Therefore, there was an initiative in place since May 2024 to improve the use of the outcome measure tools. The trust demonstrated from their data that from March 2024 until March 2025 there had been a marked improvement in the scores of those people who used services post discharge from services. Scores had improved from early to mid 40’s, out of a possible 50, for people who had used services.

The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

Staff explained to us that the social recovery model they used empowered people who used services, as the model assisted people to come up with their own goals and outcomes and their confidence was improved as part of the treatment. The community teams were supporting 172 people who had community treatment orders (CTO). There was a process in place to ensure that people had their section 132 rights read to them and that they understood their rights to access to an independent mental health advocate (IMHA). The trust had an up-to-date Community Treatment Order policy.

For people who used services who might have impaired mental capacity, staff assessed and recorded capacity to consent appropriately in the majority of times. In care plans we saw staff had completed mental capacity assessments where required and had documented informed consent.

We saw a capacity assessment had been completed for a person who was prescribed Clozapine, and another informed consent for receiving a long-lasting injection. In 3 care plans out of 21 however, we found that the section concerning consent had not been completed.

The trust shared with us how they used different methods to obtain feedback from people who used services which included gathering feedback at community events.

Staff received training in the Mental Capacity Act in line with the responsibilities of their role and 89.19% of staff had completed their Mental Capacity Act training.

We saw the trust had a policy on the Mental Capacity Act and staff were aware of the policy and had access to it. Staff knew where to get advice regarding the Mental Capacity Act.