Norfolk and Suffolk NHS Foundation Trust

On this page

• 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

At our last assessment we rated responsive as requires improvement. At this assessment the rating went up to good.

People’s needs were being met and the service made sure people were at the centre of their care and treatment choices. The service included people who use services and carers to help shape service improvements. Staff made reasonable adjustments to support people to access services. However, there were waiting lists in the community teams for people waiting after assessment to be allocated a care coordinator and treatment. In some care plans there were parts missing and not enough detail. The patient record system was difficult to use and information was not consistently stored. The services did not always demonstrate that they were meeting their own targets to carry out assessments for people who required services.

This service scored 64 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

In some care plans there were parts missing and not enough detail, the patient record system was difficult to use and information was not consistently stored. However 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.

During our inspection we saw examples of how staff in the services provided person-centred care. Staff demonstrated how they worked with other professionals and voluntary agencies to ensure that they had a good understanding of people who used services individual’s needs. The ADHD team attended team meetings in one location and in 2 locations staff had undertaken training to carry out autism assessments. Staff explained how the therapy models were adapted for individuals and how individuals could access information online.

Care plans we reviewed were mostly person-centred and individualised, reflecting people’s recovery goals. Staff regularly reviewed and updated the care plans; however, we found that 7 of the 21 care plans were not completed fully or had enough detail. While on inspection we found the patient record system was difficult to use and managers told us it was difficult to use as an audit tool. Staff told us that there were several ways to record information, and we saw that staff did not consistently record information in the same place.

People who used services told us there was a flexible approach, for example they were offered phone appointments during school holidays rather than face to face home visits and carers told us the care and support was person centred.

We saw that staff who ran the various medicines clinics had a good knowledge of the people who attended their service. They celebrated successes, the people who used services lives and worked with them to provide a service that met their needs. For instance, at one location, staff came in over the weekend to run a clinic for people to reduce the impact on their personal and professional lives. At another location, staff would actively go to people who used services in the local community to ensure they got their medicines administered at the correct time.

Care was always supportive of choice and continuity and the service understood the diverse health and care needs of people and their local communities, so care was joined up and flexible.

Staff ensured, where appropriate, that people who used services had access to education and work opportunities. Staff knew how to support people who used services to access the trust’s recovery college. We heard from staff that they linked into other voluntary organisations such as supporting access to employability workers.

Staff told us about many person-centred recovery-based activities which were available. For example, staff had set up a table top role playing group and people told us they really enjoyed being part of a social group. At one location, staff and people who used services had access to sailing activities. One person who used these services said taking part in this activity was a big turning point in their recovery. Staff ran wilderness therapy sessions in one location, which involved bushcraft skills and therapy and took place in a local wood.

Staff supported people who used services to maintain contact with their families and carers. Carers told us that there is good carer involvement, and they felt always included.

The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

Staff ensured that people who used services could obtain information on multiple topics such as treatments and local services that were available. We saw a range of information leaflets in waiting areas and these were available in different languages.We saw governance systems protected the confidentiality of people who used services and staff used computer systems to record individuals’ information.

The services complied with the Accessible Information Standard. The Accessible Information Standard is a legal requirement for organisations providing NHS care to ensure that people with disabilities or sensory losses receive information and communication support in a way they can access and understand. Staff followed a process of formal approval to ensure written leaflets and information for carers and people who used services adhered to this standard. Staff told us about easy read leaflets and the ability for these leaflets to be translated into different languages.

Staff ensured carers, families and commissioners were regularly updated about the people who used services progress. Carers told us there was good communication between services, one carer told us the care coordinator is very helpful and there is ongoing dialogue and a continuous thread.

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.

Staff told us that people who used services, and their carers had many opportunities to be involved in service development and improvement. People who used services and carers were invited to attend involvement meetings and the trust shared they had set up monthly service user and carer councils to strengthen involvement. Staff in some services told us people were always involved as part of the recruitment panels and co-produced internal training for young people.

People who used services and carers knew how to complain. Carers told us complaints were resolved quickly, Following an issue where a person using services had to wait a long time for their calls to be answered, managers told us the team employed another person within a week.

People who used services and carers told us they felt listened to and staff were responsive to complaints and made sure that most people were kept informed and provided clear updates. Staff were able to describe the complaints systems to us and the process for people who used services and carers to provide feedback by using a QR code which took people straight to a complaints or compliments page. People could also complete feedback cards and information about providing feedback was included in carers packs. Staff described a time when feedback from people who used services resulted in a change; people were struggling to get through on the phone lines as they were so busy, an IT queuing system was introduced which allowed people’s calls to be answered and held in queue waiting to be answered. Staff told us they discussed complaints and compliments as part of their team meetings.

We saw from February 2024 to January 2025 there were a total of 135 complaints of which 32 complaints were upheld. In the last 12 months there was a total of 1 complaint referred to the Ombudsman (July 2024) this complaint was not upheld. Common themes of complaints were discharges that were not planned and where there was little ongoing support, insufficient medication reviews, poor staff attitudes and cancellation of meetings.

Teams told us about patient and carers participation groups and coffee mornings the trust held to encourage carers and families to be involved.

The services did not always demonstrate that they were meeting their own targets to carry out assessments for people who required services. However the services did show that average waiting times were meeting targets.

At the time of the last inspection 2023 the average waiting times for an assessment was 45 days. The target waiting times from referral to assessment was 28 days for the CMHTs and 14 days for the early intervention teams. This had improved since the last inspection. We saw trust data that teams were generally meeting their targets with some teams exceeding their targets. However, 2 teams were missing targets by 2 weeks.

We saw that average wait times for people who used services, from their first attendance to assessment was 5.4 days.

The trust achieved their own target of 72 hours to contact people who had left hospital and been discharged into the community 91.58% of the time.

People who used services told us there was a flexible approach to care provision and staff would provide phone appointments instead of face to face when this suited a person’s schedule better or if they were impacted by other concerns, such as anxiety.

Staff told us they struggled sometimes with communication with staff from the acute mental health wards as they did not always provide the most up to date information of when a person they were going to support, was to be discharged. Staff told us in West Norfolk that they were part of a new programme aiming to achieve better health access across the county and reduce health inequalities.

We observed teams using a daily duty rota for people who used services to contact the teams by telephone. We saw managers ensure that the duty rota system was staffed daily. However, we did observe in 1 team that a member of staff was off sick and there was no cover arranged in this case. Staff on duty could also be taken off duty, to provide front line cover to people who used services, leaving the duty phone to be left to an administrative postholder to answer calls and relay any urgent messages to a manager. This meant that at times the duty service was inconsistently covered in some teams.

Staff and leaders actively listened to information about people who are most likely to experience inequality in experience or outcomes and tailored their care, support and treatment in response to this.

Staff received training in equality, diversity, inclusion and human rights. The trust was exceeding their own targets, and all teams were compliant with a compliance rate of 99%.

The provider had undertaken equality impact assessments of their policies and procedures to ensure they did not place vulnerable people or people with protected characteristics at a disadvantage. Managers could access equality impact assessment templates and guidance to support them when reviewing or developing policies and procedures.

The trust had an action plan to embed the Patient and Carer Race Equality Framework across the trust 2025/2026. We saw the Trust had assessed itself against NHS England’s patient and carer race equality framework (PCREF). PCREF is a mandatory framework for trusts to follow to become actively anti-racist organisations by ensuring that they are responsible for co-producing and implementing concrete actions to reduce racial inequalities within their services.

Staff followed a reasonable Adjustments Policy which outlined the trusts legal duties under the Equality Act.

Discharge and crisis plans were not always found in care plans. However 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.

We reviewed 21 care records. We saw evidence of good planning for discharge and crisis plans were clear, however in a 2 of the care plans we reviewed, discharge planning was missing and 4 care plans there was no crisis plan. We saw there was not enough detail in care plans in the Community Mental Health Services but generally in the Early Intervention teams there was more detailed information.

Staff told us they had good relationships with the crisis team and ensured all relevant healthcare professionals and other relevant bodies were involved in planning the care and treatment and when people’s mental health fluctuated.

Staff told us that staff delivering attention deficit hyperactivity disorder (ADHD) services and voluntary agencies attended their team meetings. Staff supported people who used services to be referred for autism spectrum disorder (ASD) and ADHD assessments, although we heard from staff that waiting lists for these assessments were long. Carers told us their loved ones were referred to other services.