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 safe as requires improvement. At this assessment the rating has remained as requires improvement. We identified 1 breach of the legal regulations in relation to medicines management, 1 breach for the environment and 1 breach for mandatory training.

Some aspects of the adult community mental health services were not always safe and there was limited assurances about safety. In some locations waiting lists were high and staff, doctors and managers told us there were high risk individuals waiting to be allocated. Communication with mental health inpatient services was not always good and sometimes people who used services were discharged without the community mental health services being aware and staff did not follow previously agreed plans. We saw in some community mental health teams plans were not completed or lacked detail. The patient record system was difficult to navigate for managers and staff. We found the service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning. The service had some systems and processes in place to safely support people with their medicines in the community. However, these were not always being followed. Areas of good practice were not widely adopted across all teams in the Trust. There were some teams and training that were below the compliance levels.

In all locations we visited, we found that the rooms staff used for people to have therapy were clinical and not therapeutic and at one location Bury South the Multi-Disciplinary Team (MDT) meeting room was not fit for purpose.

However there was a positive culture of safety and lessons learnt and safeguarding processes were well embedded.

This service scored 47 (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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The trust provided guidance to staff on the Patient Safety Incident Response Framework (PSIRF) and staff received patient safety training as part of mandatory training requirements. PSIRF is the NHS’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents for the purpose of learning and improving patient safety.

Across community mental health services 99% of staff had completed level 1 and 97.9% level 2 patient safety training. At the time of inspection clinical decision panels were held fortnightly to review patient safety incidents and consider learning and actions taken and any themes. When we reviewed the patient safety incidents from the last 12 months, we saw the trust had actioned learning from incidents. The trust reported to have had no never events in the last 12 months. Never events are serious incidents that are wholly preventable because guidance or safety recommendations should have been implemented.

A Prevention of Future Death Report from the Coroner 15/07/2024, highlighted a requirement that people who used services with short term memory difficulties would miss appointments if their advocate was not updated with timings and any changes. Following this report, there was evidence that changes had been made as a result of feedback which included the trust updating their IT systems and record keeping procedures, ensuring that correspondence was also sent to people’s advocates.

The trust issued safety and good practice alerts to staff and discussed these as part of team meetings. The patient safety team were responsible for ensuring actions were completed in a timely manner. We saw in team meeting minutes that learning from safety incidents and complaints were included. We observed learning from incidents being discussed in team meetings and we reviewed 3 patient safety incidents. The trust used various suicide risk and management skills training as well as a personalised approach to safety to enable staff to better support people who used services who were at risk of taking their own lives. The patient safety team formed part of a new safer care team which included multiple teams to facilitate a centralised approach to the provision of safe care.

All staff we spoke with reported all incidents using the trusts incident reporting system and explained how these incidents were investigated by the patient safety team and there were immediate changes made if there was learning from these incidents. Staff told us the feedback loop to staff had improved. We looked at 3 patient safety incidents and saw the trust had reviewed these appropriately and planned actions following incidents.

Staff understood the duty of candour and were open and transparent and gave people and families a full explanation when things went wrong. We reviewed duty of candour letters and saw staff offered face to face meetings and signposted to appropriate support. Staff explained the investigation process and expressed sorrow for the incident. People who use services told us that errors were corrected responsively. The trust had a specialist family liaison service to support families and carers. The safer care team worked with families and people who used services to ensure condolence letters were appropriately and sensitively written.

The trust had 97 events from February 2024 to February 2025 where the duty of candour was applied and staff had the necessary guidance to follow. Staff told us they received feedback after the investigation of incidents, both internal and external to the service, received trust bulletins, discussed incidents during safety huddles and Multi-Disciplinary Team Meetings (MDT) staff supervision and reflective practice sessions and received protected time to discuss these in staff meetings. Staff told us they were debriefed and received support after a serious incident. The trust used TRiM (Trauma Risk Management) to support staff who had experienced trauma in their work and staff received debriefs from the psychology team and referrals to wellbeing organisations if needed.

People who used services did not always have timely access to treatment; therefore, people’s mental health and well-being was at risk of deteriorating. In some locations waiting lists were high and staff, doctors and managers told us there were high risk individuals waiting to be allocated to a care coordinator. Communication with mental health inpatient services was not always good and sometimes people who used services were discharged without the community mental health services being aware and staff did not follow previously agreed plans.

People who used services were initially assessed by the Access and Assessment Team and triaged. Staff told us there were 4-hour targets for urgent assessments and 7 days to a month for more routine assessments. The trust target waiting times from referral to assessment was 28 days for the Community Mental Health Teams (CMHTs) and 14 days for the early intervention teams. The trust's referral and admission processes ensured that all essential information about people who used services was received to determine if an individual’s needs could safely be met. We saw that 87% of people referred to the Early Intervention in Psychosis Service in December 2024 received their first appointment within 2 weeks.

Community Mental Health Teams held a local policy for allocation and management for people who were waiting to be allocated a care coordinator after assessment. Staff were aware of this policy and told us that everyone was known who was on this list so these individuals could be supported and signposted to other services. A prioritisation tool was used to manage this caseload. However, in some locations waiting lists were high and staff, doctors and managers told us there were high risk individuals waiting to be allocated. Most people were on a programme of support and were contacted regularly depending on their prioritisation. Staff and managers told us they had a case load and an unallocated case load that they managed (which is the wait list). Within the community mental health teams, duty workers triaged new assessments.

There was a comprehensive policy and framework that staff used when people who use service did not attend or disengaged from services and when they shared protocols with primary care services. The trust held regular multi-disciplinary meetings to review and discuss the risks of people who used services and plan for any actions required and regular network meetings to plan pathways between services.

Staff involved all the necessary healthcare and social care services to ensure people who used services had continuity of safe care, both within the service and post-discharge. Staff told us that discharge was agreed by the MDT and people were discharged to GP’s and other professionals, including services and to the recovery college to ensure people got on-going support. However, staff told us that internal services, eating disorders and Attention Deficit Hyperactive Disorder (ADHD) assessments had long waiting lists.

Staff told us communication with mental health inpatient services was not always good and sometimes people who used services were discharged without the community mental health services being aware and staff did not follow previously agreed plans.

Staff told us that in some services they were working towards using the treatment model for 90% of caseloads so that people who used services discussed discharge from the beginning of their treatment.

People who used services told us they knew who to contact if things were at risk of going wrong or their mental health was deteriorating, However, a carer told us their family member was discharged without any paperwork and the discharge process lacked structure.

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. Staff had been trained to level 1 in safeguarding adults and children but there was room for improvement in training levels for level 3.

The trust had comprehensive policies for safeguarding adults and children.

Staff told us they could access support from the trust’s safeguarding team when they needed it. This team also provided staff with feedback on safeguarding incidents and alerts.

Staff were aware of the processes of raising a safeguarding concern and understood the trust policies and procedures. Staff completed online incident reports for all safeguarding referrals which were reviewed by the trust’s safeguarding team. Between December 2024 and February 2025, 26 safeguarding referrals had been submitted by the Community Mental health Teams and 14 by the Early Intervention teams within the service.

Staff told us they had monthly assurance meetings, and any complaints were copied to their safeguarding teams. We observed that themes and agenda items from safeguarding concerns were discussed in team meetings and daily safety huddles as well as communications from the trust. There were good links with local safeguarding teams when there were safeguarding issues.

The service’s patient recording system was difficult to use by staff and managers which impacted the services ability to have a good overview of all individuals’ risks.

We looked at 21 risk assessments and risk management plans within care records during the inspection. We saw that risk assessments were in place and had been updated, people’s risks and early warning signs of people who used services being unwell were listed. We saw evidence that family and carers had been included, and risks discussed. Mostly we saw detailed safety plans, crisis plans and robust recovery plans especially within the early intervention services.

However, we saw in 4 records that crisis plans were missing. We also saw 1 out-of-date risk management plan and another that lacked detail. Of recovery plans we found 1 did not evidence what the staff were doing in practice, 1 was not up to date and another was partially completed. We found the patient record system difficult to navigate and although information was mostly recorded, staff were not always recording information in the correct place, for example care plans in the care plan section.

Managers told us they completed regular audits of care plans of their staff and highlighted if there were any areas that required improvements. However, managers told us that using the patient record system meant there was a lot of swapping between screens when carrying out audits which was time consuming.

Staff told us that people who used services were central to risk assessment including medication reviews, discussion of their risks and triggers, safety plans and how to keep safe, this information was reviewed every few months to identify any changes. Risk assessments we reviewed were mostly person-centred and individualised. Staff told us the therapy tool used was the social recovery model, which was based on an person’s goals, and was a person-centred tool which was collaborative in its approach and empowering for the person.

Staff enabled people who used services to give feedback on the service they received and used the trust’s Friends and Family Test and encouraged carers and friends to give feedback through a variety of methods. Across the trust we saw there had been a marked improvement in feedback from friends and family since 2022 when 66% respondents thought the services were very good or good as this had now increased to 80%.

People who used services were given the choice of who they wished to share their safety plan with, and carers told us that medication was clearly explained, regularly reviewed and they felt listened too. A carer told us they understood their family risks better since they had received support from the community mental health team.

The trust had an up-to-date Clinical Risk Assessment and Management Policy which provided a framework for the assessment and management of clinical risk.

In all locations we visited, we found that the rooms staff used for people to have therapy were clinical and not therapeutic and at one location the multi-disciplinary team (MDT) meeting room in Bury South was not fit for purpose.

We saw that teams and buildings had site-specific risk assessments and community teams had a safer premises plan. There was an estates and facilities strategy 2024-29 which set out a plan for the management and development of their estates for the next 5 years. However, staff told us that rooms where they saw people who used services were not sound proof and so raised voices could be heard from outside, it was not easy to book rooms and the rooms needed a more relaxed atmosphere as they were office-like, soul-less and over-bright. In West Norfolk and Great Yarmouth, the rooms were bright and clinical and raised voices could be heard from outside the rooms. In Lowestoft, staff told us new premises were being sought, as the building was not suitable due to difficulties with neighbouring premises and unsuitability of the rooms for therapeutic work. Staff told us this was on the risk register, and this was evidenced by the Trust.The building was used by both children’s and adult services so had separate waiting areas. In Great Yarmouth there was no dedicated room for physical observations and no privacy curtains and therefore physical health equipment had to be stored in another room on site.

We observed the MDT meeting at the Bury South community mental health team. The MDT meeting was always held in the team working space as there was no other meeting room available at the team building. The space consisted of 2 rooms which had been partially opened into one space. Due to the shape of this room, it was almost impossible to hear conversations that were held even a small distance away. The team was sharing clinical information including updates about risk and planning for interventions and appointments. Much of this was inaudible from one side of the room to the other meaning that important information for individuals was not effectively shared and discussed by the team as a whole.

In the Suffolk Coastal location there were no rooms for people who used services to visit and be seen although this did mean that staff in this location were working very creatively with the people who used their services by meeting them at home or in other locations such as coffee shops. People who used services told us home visits could be arranged if they found attending the office difficult.

In the services we visited, people who used services used meeting rooms that were accessible on the ground floor. Staff told us there were some meeting rooms in Lowestoft that were not accessible for people with mobility difficulties as they were on the first floor. In Great Yarmouth, the psychology team told us, and we saw the therapy rooms were often too bright and did not provide a good therapeutic environment.

Clinic rooms were fully equipped, however, during inspection we saw in West Norfolk there were issues with privacy and dignity, the door glass was not fully covered and there were 2 windows inside with partial coverings, which meant people from outside could see inside the room when people were receiving treatment. There were blinds in place, but staff were not using these. We recommended to the trust that the blinds were pulled when providing care interventions. After highlighting these issues to the trust, the recommendations were accepted, and the trust told us that immediate learning was shared across the localities to be actioned.

Staff demonstrated they carried out regular risk assessments of the care environment, we saw that service areas were clean, temperature controlled and well maintained with appropriate medicine storage facilities. Areas where people who used services visited, all had anti-ligature fittings. We saw posters and information for people and their families in the areas that they used. Staff had alarms and there were alarms in the clinic rooms.

Managers and staff felt safe and supported each other. Staff used different methods to keep themselves safe. In Great Yarmouth there was a signing in and out board for staff which was checked off at 4pm at the end of the day. Other teams used mobile phones to relay they were safe at the end of the day.

The service did not always make sure there were enough qualified, skilled and experienced staff to provide safe care. Managers struggled to recruit substantive consultants into permanent roles. Mandatory training for some teams and training was below compliance level.

Trust data showed that at the end of February 2025, there were 16.06 whole time equivalent (WTE) vacancies across the 16 community teams. Managers were using bank staff to cover vacancies.

Vacancies (WTE) across the teams

East Suffolk - 3.3

East Suffolk Coastal - 2.78

West Suffolk Bury North - 7.86

West Suffolk Bury South - 5.65

West Norfolk - 2.68

Central Norfolk - 1.36

Great Yarmouth - 4.22

Waveney - 4.65

Central Norfolk South - 3.56

Staff told us that although there were still vacancies across the teams there had been improvements in staffing. Managers and staff told us there was a shortage of medical cover across the CMHT teams, with few consultants in substantive posts. The West had a locum consultant and in Great Yarmouth the consultant was in training. In Bury South there was 1 vacancy, and in West Norfolk, managers found recruitment and retention of consultants difficult and struggled to obtain cover for holidays. Managers told us there was a long and complicated process to obtain holiday cover and locum consultants could not provide supervision for staff. In the Great Yarmouth Early Intervention Team, the consultant was part time and there was no cover for their leave. In the West Norfolk CMHT staff told us there was currently no care coordinator for the coastal area of the team, so people who used services in that area were on a waiting list. In Great Yarmouth on the day of inspection, managers were assisting to cover duty as the person who had been assigned was off sick. We observed in Great Yarmouth, duty cover could also be hands on, assisting people in the community. The trust data told us there were 6 pharmacist vacancies (including a consultant pharmacist) and there was a business case for additional pharmacy support for the CHMT. We saw this business case dated February 2023, however time frames for implementation were once the plan had been approved, and we saw no confirmation of this.

There was a good mixture of staff and therapy teams including family therapy and peer support workers. Psychology support was being provided with minimal vacancies across the teams 7.6 FTE and psychologists told us waiting lists were low, we saw no other evidence of this.

The data from the trust showed that in most locations there were limited unfilled shifts due to staff vacancies or sickness with the majority filled by bank and agency staff. In January there was 1 shift not covered in East Suffolk Coastal, in February 2 shifts not covered in West Suffolk Bury North and in March no shifts not covered. In Ipswich however there were sickness levels of 15.67% in February 2025 8 out of 15 teams exceeded the trusts target of 4.91%.

The trust provided a comprehensive induction programme for all staff and staff told us they were introduced to the leaders at this time. However, there were low levels of compliance for mandatory training in some teams for some training. The trust policy stated that mandatory training compliance should be 85%. Basic life support resus level 2, 13 out of 16 teams fell below the trust target of 85%.

77% City 2 Adult CMHT - Central Norfolk

73% City 3 Adult CMHT - Central Norfolk

57% North Norfolk West Adult CMHT - Central Norfolk

69% South Norfolk West Adult CMHT - Central Norfolk

80% Ipswich Community Team-East Suffolk

78% Coastal Community Team-East Suffolk

67% Central Community Team-East Suffolk

54% Bury North Community Team-West Suffolk

79% West Norfolk Community Team

76% Great Yarmouth Community Team

79% Waveney Community Team

67% Early Intervention West Norfolk

78% Early Intervention West Suffolk

At the time of assessment, 15 out of 16 teams had met the 85% trust target for safeguarding level 1 (83%) however 6 out of 16 teams had not met the 85% target for safeguarding training level 3 including one team that had a score of 67%.

67% North Norfolk West Adult CMHT - Central Norfolk

79% South Norfolk Adult Team - Central Norfolk

83% Ipswich Community Team-East Suffolk

84% Waveney Community Team

72% Early Intervention West Suffolk

All teams had reached the target for Safeguarding Children Level 1 but 8 out of 16 teams had not reached the trust target of Safeguarding Children Level 3.

Below trust target 85% - safeguarding training children level 3

82 % City 1 Adult CMHT - Central Norfolk

82% City 3 Adult CMHT - Central Norfolk

60% North Norfolk West Adult CMHT - Central Norfolk

83% Central Community Team-East Suffolk

80% Bury North Community Team-West Suffolk

74% Great Yarmouth Community Team

82% Early Intervention West Norfolk

69% Early Intervention West Suffolk

Managers provided supervision to discuss case management, to reflect on and learn from practice, for personal support and professional development. The data the trust provided showed supervision compliance rates across all teams were in target above 85% and with a range between 93-100%.

Hellesdon Hospital did not have a dedicated clinic room or immediate access to hand washing facilities when administering medicines. However 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.

We looked at clinic rooms, consultation rooms, reception areas and waiting areas at the locations we visited. Cleaning records were up to date and demonstrated all areas were cleaned regularly. We observed all areas where people who used services accessed and all were clean, had good furnishings and were well-maintained. The trust had appropriate policies and guidance for staff to follow in relation to preventing and controlling infections. Staff adhered to infection control principles, including handwashing. There was antibacterial hand gel available for people and staff to use.

Clinic rooms were also temperature controlled and had appropriate medicines storage facilities.

However, in the clinic room at G-Block we found blood samples stored together with medicines in a fridge. This was an infection control risk. We highlighted this during the inspection and immediate action was taken. Also, Hellesdon Hospital did not have a dedicated clinic room or immediate access to hand washing facilities when administering medicines, staff told us they used one of the clinic rooms on one of the other wards on the premises which were not easily accessible.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning.

The service had some systems and processes in place to safely support people with their medicines in the community. However, these were not always being followed. Areas of good practice were not widely adopted across all teams in the trust.

Local teams had meetings which occurred every morning. During this, patients at risk of deterioration were discussed and action plans were set out. These were continuously reviewed to ensure actions had taken place. People who were under a Community Treatment Order (CTO) had their legal documents reviewed regularly to ensure these were still appropriate. CTOs were used effectively to support people to continue taking their medicines. In the early intervention psychosis team based at Chatterton House we saw comprehensive care plans in place for people under a CTO.

The clinical pharmacy service across the trust was inconsistent with direct support limited to only 3 community mental health teams out of 23. When pharmacists worked within community teams, they supported clinicians to review people’s medicines and improve patient safety. There were pharmacy technicians embedded into the trust’s clozapine clinics (clozapine is an antipsychotic medicine with strict monitoring requirements). They worked closely with the community teams to ensure continuity of care and positive outcomes for patients.

Medicines reconciliation (the process of gathering an accurate list of the medicines prescribed for a person) were not routinely completed. Staff were reliant on using a single source of data which was sometimes incomplete or inconsistent in the information which it held. For one person prescribed a long-acting injection, records were unclear and inconsistent about what medicine the person was prescribed and what dose they were on. We could not be assured that the correct information was available for staff including at transfer of care.

We saw a person was prescribed high dose anti-psychotic therapies (HDAT is where people are prescribed anti-psychotic medicines at doses above the usual combined daily amount in the BNF). The trust didn’t have oversight of this and had no processes in place to ensure people prescribed HDAT in the community were monitored to keep them safe. People’s GPs and the provider were not working collaboratively to share information about the prescribing and monitoring of these medicines where responsibility was shared.

The physical health serious mental illness (SMI) team in Suffolk were well developed and worked proactively to engage with completing checks of people’s health when diagnosed with a SMI. However, in Norfolk this service wasn’t as well established. Some CMHTs had local processes to ensure physical health monitoring was completed. However, we could not be assured that issues identified were always followed up. We saw two people with raised prolactin levels with no action recorded to manage this. This put people at an increased risk of experiencing adverse effects from medication on their physical health. Staff told us they spoke to people about side effects they were experiencing, however the trust did not use a recognised side effect rating scale to record this. This meant there was no record if a person was improving or deteriorating over a set period.

Some people were prescribed olanzapine long-acting injections (an antipsychotic injection with recognised health risks following administration). The Trust had a general policy in place for the use of olanzapine depot injections. However, a standard operating procedure to support staff with how to monitor and record people’s health after administration wasn’t available to all staff. Staff we spoke to were unsure what they would do if a person decided to leave the building before the 3-hour post dose monitoring was completed, there was no process in place to inform the person of the risks and what to do if they had any concerns.
The adrenaline (emergency medicine for anaphylaxis) stored at Hellesdon hospital was out of date, this was removed once raised by the inspection team and replaced.