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 well-led as requires improvement. At this assessment the rating has improved to good.

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 and analysed data about outcomes and performance. They used this to identify improvements.However recent changes to the leadership structure meant it was not always clear the trust had a shared vision, strategy and culture.

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.

Recent changes to the leadership structure meant it was not always clear the trust had a shared vision, strategy and culture.

Staff mostly knew and understood the trust’s vision, values and strategy and how they were applied in the work of their team. Staff told us they focused on the trust values during their induction and also at meetings with trust leaders. The trust’s diversity and inclusion values were covered as part of the induction programme. They were aware of the current clinical strategy and the trust’s current focus on heath inequalities. Staff were aware of the recent changes as part of the trust’s transformation and reorganisation of its services.

The trust had a clinical strategy for 2024 to 2029 and the priority within the clinical strategy for 2025 to 2026 was addressing health inequalities. The clinical strategy aligned with key national priorities such as the NHS Core20PLUS5 and the NHS Long Term Plan. The NHS Core20PLUS5 is a national NHS England approach to inform action to reduce healthcare inequalities at both national and system levels. The NHS Long Term Plan aims to ensure taxpayers’ money is invested in ways that provide high quality lifesaving treatment, care for patients and their families, and, as a result reducing pressure on NHS staff and investing in new technologies. The strategy recognised the importance of co-production with people who used services, carers and system partners.

The trust had an estates and facilities strategy for 2024 to 2029, which aligned to national NHS policies and priorities and included projects to ensure environments were safe and met regulatory standards.

Following the recent transformation, most staff told us they knew who their new managers were and there were clearer structures in place to know how to escalate risks if this was required. However, some staff were not sure who their managers were and felt a disconnect from the senior leaders. Some staff told us they had to reapply for their jobs and told us that new leaders had not had an opportunity to visit all locations.

Staff told us their immediate managers were responsive, but leaders made decisions quickly and often changed everything at the same time. There was not always clear communication or a clear rational given for decisions made.

Staff told us there was a recent instruction that staff had to take all their leave by the end of March 2025. This had caused some disruption to teams and individual members of staff. The trust told us this was not a change in policy; however, we saw while on inspection that some services were left short while staff responded to this directive.

Since the recent transformation staff felt there was a disconnect with senior leaders and there was limited face to face visibility. Therefore, staff had limited assurance that senior leaders understood the services they managed.

However local leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Staff and managers reported strengthened leadership support and some visibility since the recent restructure at the service and team level. They said they felt more confident that leaders would respond to concerns and issues. Managers told us clinical leadership had been strengthened and clinical and operational leaders worked alongside each other to support managers and staff.

Staff reported local leaders were approachable and supportive. Staff gave examples of leaders responding when incidents were reported to ensure the welfare of staff.

Staff told us they had access to leadership development training and opportunities.

Staff and managers told us there had been a shift in culture giving staff the opportunity to speak through blogs, emails and initiatives from the trust. Staff we spoke with said they felt supported in their teams and locations as there was a good level of mutual support.

However, staff told us they would welcome more opportunities for face-to-face contact with senior leaders as currently they felt disconnected from senior leaders. Senior leaders were not often visible in services and approachable for people who use services and staff we spoke too wanted this to happen more regularly to give them the confidence their leaders had sufficient understanding of the services they managed.

The service fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff we spoke with stated they felt able to raise concerns and were aware of the whistleblowing policy.

The trust’s freedom to speak up policy was available to staff on the intranet. We saw the trust monitored the themes raised monthly and agreed recommendations for changes due to feedback received from staff.

The freedom to speak up guardian service had previously been provided by an external agency. At the time of our inspection the trust had brought this service back into the trust and appointed an internal freedom to speak up guardian. The transition to a fully internal service was due to be completed by the end of March 2025. The external guardian service submitted quarterly reports to the board, highlighting themes from concerns raised by directorate so these could be addressed.

Staff described a positive culture in their teams, with open communication and an ability to have open and honest reflection with each other.

Leaders encouraged staff to raise concerns and staff felt comfortable to do so, without fear of retribution. Staff were aware of the role of the freedom to speak up guardian and knew how to contact them. Staff told us that they knew the process to speak up and felt confident and safe raising issues.

The trust’s freedom to speak up policy followed expectations for NHS services. We saw the trust regularly monitored the themes monthly and agreed recommendations for changes.

The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Staff told us there were many staff networks available and they were supported by the trust to join. Networks included LGBT+, women’s and menopause.

Flexible working agreements were available for trust staff to accommodate 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 and the trust, within their (Workforce Disability Equality Standard) WDES action plan, were reviewing how the quality of these could be improved with the aim to support and retain staff with disabilities. The trust had a reasonable adjustment policy and toolkit to support staff and managers. One staff member told us the trust purchased them a particular desk and chair due to their arthritis and many staff told us their hours were flexible to accommodate their individual circumstances. The trust was compliant with the requirements of the Workforce Disability Standard (WDES) and the Workforce Race Equality Standard (WRES). The trust had acted on areas for improvement by ensuring recruitment panels for roles at senior leadership roles reflected the diversity of all stakeholders.

We heard the trust ran events during the year such as Purple Light up in November which had generated engagement and positive feedback from disabled staff. We saw the trust undertook equality monitoring of staff within the service to ensure it was diverse in its make-up and representative of the people who are supported.

The trust had a network of 28 inclusion advocates who supported a network of champions to promote key People and Culture Strategy Interventions. This meant staff had access to peers with additional training who could support them by signposting and offering anti-racism and cultural transformation interventions.

The trust had a mentoring and reverse mentoring scheme and had introduced a disability passport. Reverse mentoring involved a more junior employee mentoring a senior colleague, with the goal of transferring knowledge, skills, and perspectives.

The trust was a Disability Confident level 2 employer and had adopted the guaranteed interview scheme.  Disability Confident is a government scheme designed to encourage employers to recruit and retain disabled people and those with health conditions. All job applications included a form which highlighted how to access support and reasonable adjustments.

The trust had developed an accessibility checklist for staff and managers and training in this was rolled out from October 2024.

The trust promoted leadership courses through equality networks to encourage staff from ethnic minority groups to apply. In January 2025, 321 staff across the trust had started the ‘empathy and equity’ training programme on race equality delivered by external subject matter experts.Training on autism awareness had been rolled out to all staff.

Priority 1 of the trust’s people and culture strategy focused on valuing people and included workstreams to implement an equality advocate network, anti-racism and LGBT+ training and to review support provided for staff to improve accessibility.The trust had assessed itself against the NHS Equality Delivery System (EDS). The EDS report for 2024 to 2025 included an action plan to address areas where the trust was not meeting the required standard. However, the report showed the trust was meeting standards for workforce health and wellbeing and inclusive leadership.

The patient record system was difficult to use and risks on the risk register had not always been actioned promptly. However 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 act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

The service had recently introduced new governance structures. Staff and managers were able to articulate clearly how information flowed up through the structures but also down to staff at daily meetings. There was a clear governance structure that described how locality management and improvement groups fed into the trust management and improvement groups and then to board level for further assurance.

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

Local managers and leaders attended weekly locality meetings, attendees included associate directors for nursing, psychology, medical, operations and business support. The meeting followed a set agenda which included review of the risk register and complaints and actions or issues which had been escalated from trust management board or its subgroups. It also included sharing good practice, as well as learning and actions from incidents and near misses. The format of meetings was the same across all localities.

Senior clinical and operational leads similarly attended weekly meetings with a comprehensive agenda.

The service had plans for emergencies which were particular to each locality and team. They included plans for loss of staff, utilities and information technology and telecommunications and gave staff clear processes to follow in such an event. The business continuity plans were reviewed and updated regularly.

Team managers had access to information to support them with their management role. This included information on the performance of the service, staffing and people who use services.

We saw managers had implemented recommendations from reviews of deaths, incidents, complaints and safeguarding alerts service level. We heard managers undertook or participated in local clinical audits. Managers told us they used audits to provide assurance and guide staff to make changes as a result when needed. The trust community teams carried out 5 audits per quarter and 1 annual audit. The trust used a dashboard for oversight and to show their performance across the trust.

Staff understood the arrangements for working with other teams, both within the provider and external, to meet the needs of the people who they supported. Staff told us however working with the acute Mental Health Units could be a challenge as communications were not always effective.

Managers held a risk register to manage risks in their teams and could escalate when they had concerns. Staff were aware of risks in their localities that were on the risk register. However, staff described some risks which had been on there for a while with no action to make improvements such as the environmental issues with the office accommodation in the Lowestoft team.

Staff had access to the equipment and information technology needed to do their work. however, staff told us that the patients’ records system was difficult to use and managers found it difficult to audit outcomes and performance from this system. On inspection we found information difficult to retrieve from this system. Staff told us the system could be used in many ways, which was confusing and led to inconsistencies in the way in which staff used it and training was not helping in this respect. The trust informed us they have plans to replace this in 2 years.

Team managers had access to information to support them with their management role. This included information on the performance of the service, staffing and people who use services.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

Managers at the service held regular meetings with external partners to ensure safe systems of care were established.

The trust were signed up to My Care Record which is the East of England’s regional information sharing agreement and had information sharing agreements with other organisations, for example a range of statutory and voluntary sector partners such as the police, schools, and voluntary organisations.Directorate leaders engaged with external stakeholders such as commissioners and Healthwatch.

Localities demonstrated they worked well and in partnership with the voluntary sector and other statutory services, they were invited to attend team meetings and open days.

The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contribute to safe, effective practice and research.

The trust had a wider improvement programme which reported on the delivery of progress on each large-scale change programme including learning from deaths and increasing inclusion and diversity. We read about the trust’s current Quality Improvements (QI) initiatives and transformation plans.

Staff were able to tell us how they shared learning as part of staff supervision and in team meetings and service improvements were made. We saw that staff had opportunities to participate in research and innovations were taking place in the service. Staff told us about QI projects they were working on, in Kings Lynn staff were working with local GP surgeries to better understand the access process for people who use their services and working with local colleges to recruit staff into the trust. In Great Yarmouth staff told us about a menopause study to review the effects of peri and menopause can have on psychosis.