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 requires improvement. At this assessment the rating improved to 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 to meet the needs of people who used services. Staff from different disciplines worked together as a team to benefit 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 75 (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 made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

During our inspection, we reviewed 19 care records of people who used services using CRHT teams and 10 records of patients using health-based places of safety. We found they contained timely and comprehensive notes, with completed and updated risk assessments and safety plans.

Records showed staff completed a comprehensive mental health assessment of patients in a timely manner at, or soon after, referral to the team. This included a joint assessment with other teams, where appropriate.

Staff followed trust policy on clinical risk assessment and management which outlined a person-centred approach to risk assessment and safety planning. It also outlined the competencies and training required by staff to undertake risk assessment and care planning.

We found care plans were recovery-oriented, individualised and holistic. Staff reviewed care plans regularly and ensured they reflected input from people who used services and, if consent had been given, from their carers. Care plans were easy to understand and met the communication needs of people who used services.

Unqualified staff in CRHT teams used a note taking template to ensure they recorded all relevant information was captured. Non-registered staff are healthcare staff who work in nursing or other roles but are not registered by a governing council in the UK. This had a positive impact on ensuring all staff had the relevant information to assess and respond to people who used services’ individual needs.

Staff assessed people who used services’ physical health needs in timely manner. We saw evidence that people who used services were allocated a physical health worker, where appropriate, to address their physical health needs and provide ongoing assessment. Audits from March 2024 to January 2025 showed an average of 81.5% completion of physical health checks across all CRHT teams. This was an improvement from our last inspection, where we found not all people who used services had a physical health assessment.

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 people who used services. The interventions delivered were in line with guidance from the National Institute for Health and Care Excellence (NICE). For example, staff could access psychological treatments and interventions, such as dialectical behaviour therapy, dependent on the needs of people who used services. They could also provide medical and nursing interventions. Some teams had access to occupational therapy input to help people who used services acquire living skills.

CRHT teams included physical health nurses to ensure people who used services had good access to physical health care. Staff had seen improvements in compliance with physical health monitoring since they had started working within their teams. In February 2025 compliance with physical health monitoring was 89%.

Staff in the health-based places of safety (HBPoS) made sure patients’ needs for food and drink were met. We saw a patient being offered a range of hot meal options and staff facilitating delivery of a take-away meal when this did not meet the patient’s needs.

Staff participated in clinical audit, benchmarking and quality improvement initiatives. For example, the 111 service had recently had an external in-depth review to look at problems identified with access to the helpline, long waits and call abandonment. Staff were taking part in quality improvement work to ensure the correct codes were used to identify the type of care provided. This would enable the service to report more accurately performance against national key performance indicators.

Not all teams within the service included or had access to a range of specialists required to meet the needs of people who used services. The Great Yarmouth and Waveney CRHT team did not have a consultant. The West Suffolk CRHT had limited funding for a non-medical prescriber and the post was vacant.

Managers ensured that staff received the necessary specialist training for their roles. For example, medical staff spoke positively about the trust continuing professional development programme and some staff had received training in self-harm and suicide prevention.

Staff received training in and had a good understanding of the Mental Health Act. At the time of our onsite inspection, all staff within the crisis team had completed their Mental Health Act training.

The provider had relevant policies and procedures that reflected the most recent guidance. They had interagency protocols relating to Section 136 and 135 of the Mental Health Act which had been regularly reviewed.

Patients in HBPoS had access to information about their rights and independent mental health advocacy.

Staff explained to patients their rights under the Mental Health Act in a way that they could understand, repeated it as required and recorded that they had done it. We reviewed 10 records in the health-based places of safety and saw rights were recorded as being given in a timely way in all records. Staff explained what a Section 136 of the Mental Health Act meant and gave patients a leaflet with a fuller explanation.

Staff had access to legal advice on implementation of the Mental Health Act. The trust had a mental health legislation group, which provided oversight and monitoring of implementation of the Act. Staff knew who their Mental Health Act administrators were.

The trust monitored the use of the Mental Health Act, including for people from ethnic minority groups, and reported this in the trust annual mental health report.

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.

Staff held regular and effective multidisciplinary meetings. We reviewed minutes of multidisciplinary team meetings for the last 3 months and saw evidence that relevant staff attended the meetings and pertinent information was shared about people who used services and their recovery. This included information from psychology, employment support and support workers.

Staff shared information about people who used services at effective handover meetings which were attended by members of the multidisciplinary team. We attended 2 handover meetings and saw they included relevant clinical information, consideration of bio-social factors and safety planning.

Staff from the 111 service referred people who used services to the crisis teams using a verbal handovers and alerts on the electronic record system. Staff were developing positive relationships between the 111 team and CRHT teams, though some staff felt they did not fully understand each teams’ specific roles.

During our inspection we saw positive examples of CRHT and community mental health teams working together to ensure continuity of care for people who used services. We saw joint visits with community mental health team clinicians planned during the morning handover, and that any concerns regarding engagement with other teams providing care were picked up and escalated appropriately.

Staff in the CRHT team at Central Norfolk gave examples of working in partnership with clinicians in the youth team to provide holistic care and treatment.

The teams had effective working relationships with teams outside the organisation. For example, staff worked with a local voluntary sector agency to effectively secure temporary crisis care or alternatives to admission beds in the community. In Suffolk, the 111 service had worked with the police to address concerns about the length of time calls took to answer.

Staff in the health-based places of safety reported positive working relationships with colleagues in social care, specifically Approved Mental Health Professionals (AMHP).

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, reduce their future needs for care and support.

The service supported people who used services to live healthier lives. We saw physical health, lifestyle and wellbeing needs reflected in care plans we reviewed.

Each team had a physical health nurse to assess risks to people who used services physical health and respond to any identified issues accordingly. They took a lead in supporting access to services which could help people who used services with healthy eating advice or smoking cessation. Staff could provide people who used services with vapes and nicotine replacement therapy.

Staff helped promote a healthy lifestyle for people who used services, with examples such a referring them to gym classes. They could refer people who used services to external addiction services to help patients with substance misuse problems.

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.

Staff used the community early warning trigger scale to assess and record severity and outcomes for people who used services. The community early warning trigger score is a tool used to identify deterioration in a person’s symptoms.

Managers and staff monitored outcomes for people who used services through regular audits completed using an online tool. We looked at the schedule for audits for health-based places of safety (HBPoS) and saw this included a monthly audit of clinical practice and quarterly audit of Mental Health Act paperwork. For CRHT teams, monthly audits included the care process, medicines, physical health and use of early warning trigger scales. Audits were planned in advance until the end of December 2025. We saw evidence that actions from audits were identified to improve care for people who used services and tracked until completed. For example, we saw action taken following low compliance with physical health checks in Central Norfolk CRHT team in April 2024, which led to an email being sent to all staff.

Audits for the HBPoS between March 2024 and February 2025 showed 88.9% compliance with clinical practice standards.

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

Staff assessed and recorded capacity to consent appropriately when it was suspected a patient’s mental capacity was impaired. Capacity to consent was considered at each assessment and recorded in the care records we reviewed. Staff gave examples of enabling people who used services to make their own decisions about their care and treatment through discussing their symptoms and risks with them and relating them to their care and safety plans.

Staff received training in the Mental Capacity Act. At the time of our inspection, 93% of staff had completed this training. Managers shared good practice alerts with staff to inform them of the key principles of consent and where this had worked well. The Mental Health Act and Mental Capacity Act teams were involved in developing training and support for staff as part of the crisis transformation programme.

Staff had a good understanding of the Mental Capacity Act, in particular the five statutory principles.

Staff took all practical steps to enable people who used services to make their own decisions, involving them fully in developing their safety plans and care plans.

Staff knew where to get advice from within the provider regarding the Mental Capacity Act, including deprivation of liberty safeguards.

The service had arrangements to monitor adherence to the Mental Capacity Act and applications were reported in the annual mental health report.

Section 136 is part of the Mental Health Act that gives police emergency powers to take someone to a place of safety where they can be kept for up to 24 hours, plus an additional 12 hours if authorised by a clinician. In the last 12 months, only 1 patient remained in the health-based place of safety for longer than the permitted period. This was in July 2024 and was by 1 hour whilst waiting assessment by a consultant. Staff followed a detailed flow chart to ensure safe and legal care of the patient in the health-based place of safety.

The average length of patient stays whilst detained under Section 136 of the Mental Health Act in the health-based places of safety from January 2024 to February 2025 was 32.5 hours. Between March 2024 and March 2025, there were 49 cases when a patient remained in the health-based place of safety after the Section 136 had expired. In all cases, a Mental Health Act assessment had been carried out, the decision had been made to detain the patient, and they were waiting for an inpatient bed. The service ensured all patients detained in these circumstances, started care and treatment and the planning and delivery of care was coordinated by a multidisciplinary team.

Patients told us they had been informed of their rights whilst in the health-based place of safety. We saw evidence in care records that staff recorded this and had provided patients with associated documentation about their rights. However, 2 patients told us they had not been offered an Independent Mental Health Advocate (IMHA) whilst detained under Section 136 of the Mental Health Act at a health-based place of safety.