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 remained as requires improvement.

The service did not always make sure people who used services could access care and treatment in a timely way. It did not always meet national standards for assessment of emergency crisis referrals and calls to the 24-hour mental health helpline were not always answered quickly.

However, staff supported people who used services to access activities outside the service, such as work, education and family relationships. The service met the needs of people who used services with a protected characteristic. Staff helped people who use services with communication, advocacy and cultural and spiritual support. The service treated concerns and complaints seriously, investigated them and learned lessons from the result.

This service scored 62 (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 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 service provided person-centred care. For example, staff in the health-based places of safety had access to a variety of puzzles, games, fidget toys and activities to help patients manage their anxiety whilst in the suite. One clinical support worker told us they did craft activities with very anxious patients to keep them occupied and alleviate anxiety whilst they were waiting for assessment in the health-based place of safety.

Staff based the care they provided of people who used services around their individual needs and preferences. In the daily handover meeting at West Suffolk CRHT, we observed staff discussions about individual preferences. They identified a staff member who could engage with the person who used services through their hobby in order to build a therapeutic relationship. Staff in health-based places of safety provided funding for patients to return home via taxi when a decision not to admit them to the inpatient service had been made.

Staff empowered people who used services to make their own decisions about their care and treatment. One person who used services described how support from the home treatment team allowed them to continue receiving their care at home, which was their preference, rather than in hospital. People who use services were supported to access further sources of information such as advocacy services and voluntary sector agencies.

Care plans we reviewed were person-centred and individualised, reflecting people who use services recovery goals. Staff regularly reviewed and updated them.

Care was not always supportive of choice and continuity due to capacity issues in the health-based palaces of safety. However, the service understood the diverse health and care needs of people and their local communities, so care was joined up and flexible.

Minutes from the mental health monitoring group showed that capacity in the health-based places of safety was a concern with the beds being used for patients other than those detained under Section 136 of the Mental Health Act. For example, in December 2024, the 2 health-based places of safety (HBPoS) in Norfolk were unavailable for 80 days in total. This was because the beds were used by patients that had been admitted to a ward, either under the Mental Health Act or informally or due to maintenance. This meant there was a risk that patients being detained under Section 136 of the Mental Health Act may not have been able to access an appropriate bed in a HBPoS and therefore, been taken to an emergency department.

Where people who use services were supported by more than one service or provider, there was continuity in people’s care and treatment because staff worked in a collaborative way.The service had adapted national shared care guidelines with primary care in collaboration with the local integrated care board (ICB), for use in the trust. We saw evidence that shared care guidelines were reviewed in medicines optimisation group meetings, including a summary of discharges made to other parties involved in the patient’s care and treatment.

Staff in the health-based places of safety worked with other teams such as CRHT and youth teams to facilitate discharge and ensure continuity in treatment.

Managers attended monthly mental health monitoring group meetings with system partners. We reviewed the minutes of the last 3 meetings in Norfolk and saw that capacity in the health-based places of safety was discussed as well as an overview of detentions under Section 136 of the Mental Health Act. Partners shared information on concerns and positive practice.

When appropriate, staff ensured 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, and we saw examples of joint working with wellbeing teams at local universities to help people who used services remain in education. Staff could refer people who used services to a service which enabled them to gain and sustain employment and staff from the employment service attended multidisciplinary meetings. In handover meetings, staff demonstrated an awareness of the importance of enabling people who used services to maintain their employment.

We saw differences in the crisis pathway across different teams and areas, with different referral routes and commissioning arrangements for the 111 service. There was an ongoing crisis pathway transformation programme to redesign the workforce structure and operating procedure across the service. Staff and managers told us they had been consulted as part of the transformation and felt listened to when they put ideas forward.

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 consulting rooms and waiting areas and these were available in different languages.

The service complied with the Accessible Information Standard. The Accessible Information Standard isa 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. They could access translation services via the intranet to translate letters, documents and information leaflets.

The trust website met accessibility standards and information could be easily accessed by making it larger or changing colours and fonts. Information on how to access crisis services was in simple text, with pictures. Staff could access information on the pharmacy intranet page in other languages, large print and easy read format to ensure people who used services were given appropriate and accessible information on the medicines they were given.

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.

The service provided opportunities for coproduction and codesign, enabling people who used services to have meaningful involvement in service development and improvement. The crisis transformation programme was supported by a service user advisory board. Some of the key changes to the statement of purpose for crisis services that were being implemented at the time of our inspection strengthened service user and carer involvement and people who used services and carers had been involved in developing it.

Staff were supported by the trust participation and Involvement team to access resources to create ‘working together’ groups to ensure they worked in partnership with people who used services and carers.

Most people who used services we spoke with confirmed they knew how to complain or raise concerns, including those who said they had no reason to complain. We saw leaflets about how to raise a concern in areas we visited. Nine out of 11 carers we spoke to said they knew how to complain or raise a concern. Four carers told us they had made a complaint and received a response.

Out of the 15 people who used services we spoke with, 13 told us they felt safe from discrimination to raise a complaint freely. They also told us they felt empowered to give their views.

The service kept a formal record of all complaints. In the last 12 months there were 3 complaints about the health-based places of safety, 7 about the 111 service and 21 about CRHT teams. Themes from complaints about the 111 service related to staff attitude, for CRHT teams they related to communication, access and discharge.

When people who used services complained or raised concerns, they received feedback. We reviewed the complaints log for the last 12 months and saw that apologies and explanations were provided, including for complaints that were not upheld.

The service took complaints seriously and investigated them. In the last 12 months 21 complaints were investigated, with 6 upheld and 7 partially upheld.

The service acted on learning from complaints. For example, the service had acted to ensure carer packs were available in all cars used by staff following a complaint from a carer about communication and not all options being explained or made available.

The service had 1 complaint open to the Parliamentary and Health Service Ombudsman (PHSO), against the West Norfolk CRHT team. There were no complaints upheld by the PHSO in the last 12 months.

Staff told us they received feedback on the outcome of investigation of complaints.

Calls to the urgent mental health helpline (111 service) were not always answered in a timely manner and there were high numbers of calls abandoned. This meant some people who used services requiring urgent help may not have been able to get through to a staff member. The service did not always meet the national standard for assessments within 4-hours of an emergency referral.

At our last inspection we found not all the teams had appropriate telephone arrangements so that people who used services could access teams in a timely manner. The service now had a 24-hour urgent mental health helpline (111 service) for professionals and people who used services, which referred people who used services to the most appropriate team. However, capacity in the 111 service did not meet the demand the service had identified. Managers had commissioned an independent review of the service which was completed in March 2025. The report analysed call data between January and December 2024 and observed calls for 3 days in December 2024. The report from the review identified 3 areas for improvement the service needed to focus on. These were around capacity, frequent callers and the current clinical model. The review also showed the average waiting time for a call to be answered by the 111 service was 6 minutes, though this varied, increasing at shift changes. The average time to answer calls across all 111 providers nationally was 4 minutes 6 seconds in March 2025. It found that 31% of calls to the public line and 17% of calls to the professional line were abandoned. It also found that a small number of people called repeatedly meaning that a few people, only 1%, were responsible for around 40% of calls. Data provided by the trust showed in April 2025 the service answered 60% of calls within 20 seconds and 28% of calls were abandoned. This placed people who used services at risk of harm as they may not be able to access the service at a time when their needs were considerably heightened.

Following an external review in September 2024 of the 111 service the trust established a crisis working group to develop an improvement plan. The service acted and recruited to vacancies in the service, introduced a revised shift pattern and commissioned an external diagnostic review of the service. This reported in March 2025. Data provided by the trust showed from 24 March 2025 to 14 April 2025 the average answer time for calls to the 111 service had dropped from 7 minutes to 2.5 minutes.

At our last inspection, we found the service did not always meet the national standard for 4-hours from emergency referral to assessment. Data provided by the service showed the monthly average time from point of referral (either self-referral or by a professional) to assessment continued to not always meet the 4-hour standard. In February 2025, only West Suffolk CRHT met this with an average of 2 hours. The average time from the point of referral to assessment by Central Norfolk CRHT was 32 hours, Great Yarmouth and Waveney 24 hours, West Norfolk 21 hours and East Suffolk 6 hours.

The percentage of people who used services seen within the 4-hour emergency standard for assessment in February 2025 was 31% in Central Norfolk CRHT, 89% in Great Yarmouth and Waveney CRHT, 80% in West Norfolk CRHT, 83% in East Suffolk CRHT and 100% in West Suffolk CRHT.

This meant the service did not always act in a timely manner to assess and respond to the risks associated with people who used services experiencing deterioration in their mental health.

The service told us actions to address the variation in performance against the 4-hour standard across CRHT teams were a focus of the ongoing crisis transformation programme.

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 were trained in equality, diversity and human rights. Compliance with training was 100% in all CRHT teams except West Suffolk where it was 97%, which was still in line with the trust target of 85%.

The provider 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.

The service monitored the use of detentions under Section 136 of the Mental Health Act in relation to protected characteristics such as ethnicity, gender and race. This was reported annually in the trust’s annual mental health report. We reviewed the report for 2024 which showed Section 136 detentions for people from ethnic minority groups were lower than the national average. It also showed that the service was in line with the national data on gender, with females more likely to be detained under Section 136 of the Mental Health Act than males. Data was shared with local managers and leaders so they could ensure that people with protected characteristics could access the same level of care and support as everyone else.

The service 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.

Staff followed a trust wide reasonable adjustment policy based on the social model of disability to ensure they prevented discrimination and made reasonable adjustments in line with legislation.

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.

People who used services were supported to make informed choices and plan their future care while they had the capacity to do so. We saw a person’s capacity was considered at initial assessment and throughout their time under the care of the team and was recorded in care records.

Staff created personalised care and safety plans to account for people who used service’s needs, wishes and feelings. Care plans reflected the individual’s specific circumstances, needs and wishes and were recovery focused.

Staff supported people who used services to make decisions about their care and treatment and their future. People who used services told us staff helped them plan what to do if their condition deteriorated and ensured they had contact details to use if this happened.

Staff ensure all relevant healthcare professionals and other relevant bodies are involved in planning the care and treatment of people with complex needs. For example, in care records we saw evidence of joint work between the youth team and the CRHT team for an individual to ensure appropriate care and treatment.