- SERVICE PROVIDER
Norfolk and Suffolk NHS Foundation Trust
This is an organisation that runs the health and social care services we inspect
Report from 15 August 2025 assessment
Contents
Ratings - Mental health crisis services and health-based places of safety
Our view of the service
We carried out an inspection of the trust’s mental health crisis services and health-based places of safety on 18, 19 and 20 March 2025. This inspection was completed as part of the CQC's Adult Community Mental Health Programme. We also inspected community mental health services for adults of working age as part of the programme. The programme of inspections contributes to CQC's commitment to inspect the standard of care in community mental health services across the country. We undertook a short notice announced, comprehensive inspection of this service, looking at all 5 key questions to assess if services are safe, effective, caring, responsive and well led.
The trust has 5 Crisis Resolution and Home Treatment (CRHT) teams, 3 in Norfolk and 2 in Suffolk. It has 5 health-based places of safety (HBPoS) at Kings Lynn, Bury St Edmunds, Ipswich, Great Yarmouth and Norwich.
The inspection team comprised 1 CQC inspector, 1 CQC analyst, 1 CQC clinical fellow, 2 CQC senior specialist in mental health, 3 CQC pharmacist specialists (also referred to as medicines inspectors), 1 Mental Health Act reviewer, 2 specialist advisors, and 1 Experts by Experience (people who have experience of using, or caring for someone who uses services).
During the inspection we:
- visited the CRHT teams at Great Yarmouth and Waveney, Central Norfolk and East Suffolk.
- visited the HBPoS at Northgate Hospital, Great Yarmouth, Hellesdon Hospital, Norwich and Woodlands Unit, Ipswich.
- visited the 24-hour urgent mental health telephone helpline (111 service) in Norfolk.
- spoke with 40 staff of various all grades and roles, including 8 staff on duty at the HBPoS.
- spoke with 17 people who used services and 11 carers
- observed care and treatment in the health-based places of safety and Woodlands Unit.
- reviewed 19 care records for people who used services, including medicines administration and associated care records.
- reviewed an additional 66 records of patients who were currently or recently subject to section 136 of the Mental Health Act
We last inspected the service in September 2022 when we rated safe, responsive, effective and well-led as requires improvement and caring as good. This led to the assessment service group being rated overall as requires improvement. At our last inspection we found breaches in regulation relating to physical health assessments, access to teams out of hours, accurate data for crisis services to support monitoring of services, sufficient staffing to meet the 4-hour target for emergency referrals and mandatory training.
At this inspection we rated the service as requires improvement. We found 3 breaches of regulation relating to timeliness of emergency referrals, access to outside space at the Woodlands Unit health-based place of safety and staffing. The HBPoS at Woodlands Unit did not allow people who used services direct access to outside space and fresh air, which is not in line with the Mental Health Act code of practice, though the service was taking action to address this. The service still did not always deploy sufficient staff in all areas, due to high numbers of vacancies in some teams, though the service was taking action to address this. The service still did not always assess emergency referrals within 4-hours in line with national standards. We have asked the provider for an action plan in response to the concerns found at this assessment.
However, the service had made some improvements and was no longer in breach of regulations relating to assessing and responding to people who used services physical health needs, data and governance, mandatory training of staff and telephone access to crisis services. The service now ensured people who used services received a physical health check and physical health needs were reflected in care plans. Managers and leaders had access to accurate data to appropriately monitor the effectiveness of services. The service now had a 24-hour urgent mental health helpline (111 service) for professionals and the general public and people who used services to access crisis services.
People's experience of this service
Feedback obtained during the CQC 2023 Community Mental Health Survey showed that people who used services felt the quality of care could improve for crisis services. Some people told us they did not get the help they needed when they last contacted the crisis team. For example, staff put the phone down on them and did not contact them back in a timely manner, if at all. Some people told us the service said the staff lacked empathy and compassion, and they did not feel listened to. Some people reported that they used other services when in crisis, such as charities, as an alternative, as they had been able to get through to the crisis line or get the help they felt they needed. However, people who used services in the Great Yarmouth crisis care team reported that it was a good service that listened to people and was responsive to their needs.
Feedback provided by carers to Healthwatch for their June 2024 report “Experiences of carers of adults with Serious Mental Illness”, included a case study which highlighted difficulties carers faces accessing crisis support for their relative, especially at night and long waits on the telephone crisis line (111 service). However, Healthwatch also received positive feedback from a carer about the crisis team in West Norfolk saying care for their relative was ‘excellent, timely and sensitive’.
We spoke with 17 people who used services. Feedback was mostly positive about staff attitudes and behaviours. People told us staff were discreet and respectful and provided them with help and emotional support. However, 2 people commented that some staff were not always helpful, and 1 person reported feeling judged by staff. Fourteen out of 17 people who used services told us staff supported them to understand and manage their care, treatment or condition and met their needs. We spoke to 7 people who used services who had been discharged who told us they were involved in discharge planning and felt the discharge process was effective.
We spoke with 11 carers of people who had used the crisis service or health-based place of safety. Feedback from carers was overwhelming positive about staff attitudes and behaviours. They told us staff understood their relative’s individual needs and they had been involved in meetings or reviews about their relative’s care.