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 required improvement.

Requires improvement: This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed. The service did not always deploy sufficient staff in the crisis resolution home treatment teams, which impacted on peoples flow through the crisis pathway. 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. The service had identified action to address this, and work was due to be started in November 2025 and completed by January 2026.

However, premises were safe, clean, well equipped, well-furnished and well maintained. Staff assessed and managed risks to people who used services and themselves well. Staff understood how to protect people from abuse and the service worked well with other agencies to do so. The service used systems and processes to safely prescribe, administer, record and store medicine. The service managed safety incidents well.

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 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 Crisis Resolution Home Treatment (CRHT), 99% of staff had completed level 1 and 99% level 2 patient safety training.

The Central Norfolk CRHT team reported 2 serious incidents which involved the unexpected deaths of 2 people who used services between March 2024 and February 2025. A patient safety incident investigation was carried out for both incidents, which identified learning and made clear recommendations. This included a review of the clinical operating model for CRHT which was taking place as part of the crisis transformation programme at the time of our inspection. The patient safety team ensured that all actions and recommendations were completed, and we saw evidence of this such as provision of additional Mental Capacity Act training for staff.

Staff knew what incidents to report and how to report them. They gave examples of the type of incidents they would report via the trust’s online incident reporting system.We looked at incidents reported between April 2024 and February 2025 for crisis services and community teams for adults of working age. Staff in the health-based places of safety (HBPoS) reported 340 incidents. Staff in crisis resolution home treatment teams (CRHTT) reported 1273 incidents in the same period. The highest number of concerns reported were regarding staffing and self-harm or threatened self-harm

The service monitored the number of incidents reported in health-based places of safety and the number of times rapid tranquilisation was administered.

Staff received feedback from the investigation of incidents, both internal and external to the service. The patient safety team sent good practice alerts where areas of good practice had been identified during an incident investigation, so staff in other teams could learn from this. Staff gave examples of changes made as a result of learning from incidents such as the introduction of daily safety huddles and changes to the triage system following the death of a person who used services.

Staff in the health-based place of safety (HBPoS) at Hellesdon Hospital described changes made following an incident when staff were injured by patients. They told us the service reviewed the standard operating procedure for HBPoS which were not attached to a ward as a result.

Staff felt confident to report incidents and met regularly to discuss learning from incidents. They received feedback from incidents reported and debriefed where this was appropriate. Patient safety alerts were sent to teams and colleagues across the trust to share actions required after learning from incidents in the crisis teams.

There were 3 prevention of future deaths reports from the coroner’s office in the last 12 months. The service had acted following these reports and provided evidence to the coroner of actions taken. Staff followed a clear process to review and learn from deaths, all of which were reviewed by a clinical decisions panel. Learning was discussed in relevant forums such as the trust safety group and the learning from deaths action plan group. We reviewed minutes of the learning from deaths action plan group for the last 6 months and saw evidence that relevant staff and partners attended meetings, including representatives of people who used services and carers.

Staff understood the duty of candour. Duty of candour is a regulatory duty that relates to openness and transparency and requires providers of health and social care services to notify patients (or other relevant persons) of certain ‘notifiable safety incidents’ and provide reasonable support to that person. They were open and transparent and gave people who used services and families a full explanation if and when things went wrong. There was an up to date and clear duty of candour policy. Senior clinicians were responsible for contacting people who used services and families and were supported by family liaison officers. Between February 2024 and February 2025 there were 29 incidents where duty of candour was applied. The safer care team worked with families and people who used services to ensure condolence letters were appropriately and sensitively written. We reviewed duty of candour letters and saw they offered face to face meetings and signposted to appropriate support. They explained the investigation process and expressed sorrow for the incident.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Staff in the health-based places of safety (HBPoS) reported that they could easily access approved mental health practitioners (AMHP) to ensure patients were assessed under the Mental Health Act in line with legislation. However, they also told us there were sometimes delays finding a doctor to carry out the assessment. Data provided by the trust showed the average waiting time for a mental health assessment within the HBPoS to assessment was 11 hours in February 2025, which is within the 24-hour period outlined in the Mental Health Act. The Mental Health Act allows clinicians to extend this period by another 12 hours.

There was an interagency protocol which had a clear escalation plan for times when anticipated times to assessment could increase or there was a risk of patients exceeding the 36-hour time limit on a Section 136 of the Mental Health Act. This included daily system wide calls with the integrated care board.

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.

On arrival at a health-based place of safety, staff received a full handover from the police using an agreed template that included monitoring of the patient whilst in custody and a risk assessment.

Staff followed the trust policy for people that did not attend their appointments, including when staff were unable to access the person’s premises or if someone left prior to the appointment ending. The policy provided a framework for staff to follow in such circumstances and was based on a trauma informed approach to care and treatment.

Managers monitored the number of people who used services who did not attend appointments using a dashboard system. The dashboard showed the number of people who used services by locality and if the person had been sent a text reminder of the appointment. It also monitored the number of people who attended appointments against the total number of referrals received.

The service’s referral and admission processes ensured that all essential information about people who used services was received to determine if their needs could safely be met.

Staff reviewed essential safety and risk information about people who used services in daily multidisciplinary meetings. Daily meetings included plans to safely meet people who used services needs and discharge planning. For example, in central Norfolk CRHT, we saw staff used the 5 P method (presenting problem, predisposing, precipitating, perpetuating and protective factors) to ensure they had all relevant information to plan visits and care and treatment.

When a person’s care was shared with community teams, staff within the service worked in partnership with them to ensure continuity of safe and consistent care. We saw joint visits planned in daily handover meetings and recorded in people who used services.

Teams used systems to categorise risk each day and identify high risk people who used services, taking appropriate action to support them. We reviewed 9 records for people who used services within the CRHT services. They showed risk assessments were completed, reviewed, updated when new information was received, and were used to support care and treatment.

Staff in the Suffolk 111 service completed a first response handover document at the start of each shift, which included relevant clinical information for the incoming staff.

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.

At the time of our assessment, 100% of staff had completed their safeguarding adult’s level 1 training and 86% had completed their level 2 training. All staff had completed safeguarding children level 1 training and 84% had completed their level 2 training.

Staff knew how to make a safeguarding alert and sent these directly to the relevant local authority. Staff completed online incident reports for all safeguarding referrals which were reviewed by the trust’s safeguarding team. Between December 2024 and February 2025, 43 safeguarding referrals has been submitted within the service.

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 could give examples of how to protect people who used services from harassment and discrimination, including those with protected characteristics under the Equality Act, such as advocating for someone with a learning disability who had been excluded from a service. Staff in the 111 service gave examples of raising alerts with the local authority for people who used services who were at risk of physical, financial and emotional abuse.

Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies. Staff reported good working relationships with local authority safeguarding teams and had worked with other agencies such as the police and voluntary sector agencies to safeguard people.

Information from the trust showed there were very few incidents of restraint or restrictive practice. Staff could access support from a trust lead on reducing restrictive practice.

The service worked with people to understand and manage risks by thinking holistically. Staff assessed and managed risks to people who used services and themselves well and followed best practice in anticipating, de-escalating and managing challenging behaviour. Staff used restraint and seclusion only after attempts at de-escalation had failed. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. However, not all people who used services said they had been offered a copy of their care plan, and carers were not always included in identifying and managing risk.

We looked at 9 risk assessments and risk management plans within care records. These showed risk assessments were completed and updated regularly and appropriate risk management plans were put in place. They showed people who used services were involved in their risk management plan, with their views highlighted and a strengths-based approach used in line with their care plan. People who used services told us they were supported to understand and manage any risks, and they knew who to contact if they felt their mental health was deteriorating or they were at risk. Thirteen out of 15 people who used services told us they had been included in identifying and planning to manage their risks. However, 5 out of 11 carers we spoke with told us they had not been included in identifying risk and risk planning for their relative, though they did not give an explanation for why this was, such as the person receiving care not giving consent.

Managers carried out a monthly care process audit in all CRHT teams throughout 2024. The audit focussed on compliance with recovery and crisis planning, against 23 safe practice standards. The audit for March to December 2024 showed compliance with safe practice standards varied between 83% in August 2024 and 90% in March 2024.

Staff involved people who used services in their care planning. We saw evidence of people who used services and carer involvement in all care plans we reviewed. Care plans were regularly reviewed; were written in a way that people who used services could understand and were recovery focused. Staff described a ‘There to Share’ approach to conversations with carers and involving them in risk management and care planning.

However, 5 out of 15 people who used services we spoke with told us they had not been given a copy of their care plan and 4 out of 11 carers told us their relative did not have a copy of their care plan.

Staff communicated with people who used services in a way that allowed them to understand their care and treatment, including finding effective ways to communicate with people who used services with communication difficulties. They gave examples of adapting their communication to meet the needs of people who used services, for example one staff member was undertaking lessons in sign language.

Staff supported people who used services, where appropriate, to include advance decisions in their care plans as part of the 3-day assessment process. Staff in the health-based place of safety (HBPoS) considered these with patients for when their detention there came to an end.

Staff demonstrated understanding of the use of restraint or restrictive practices as a last resort. They received training in conflict resolution, with 100% of staff having completed the training at the time of our inspection.

The service monitored the use of restrictive practices such as physical restraint or rapid tranquilisation through the trust’s incident reporting systems. We reviewed reported incidents between March 2024 and February 2025. There were low numbers across teams, with some higher numbers noted in West Norfolk in March and December 2024. The service reported these were due to 1 patient in the HBPoS in March 2024 experiencing high acuity and 1 patient in December who was particularly distressed.

Staff enabled people who used services to give feedback on the service they received. People who used services and their carers could use a QR code which linked to the family and friends test which people could use to leave feedback via an app.

Staff ensured that people who used services had access to an independent mental health advocate (IMHA) when needed. In some teams, such as Great Yarmouth and Waveney, staff could access navigators who acted as advocates for people who used services with autism.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. However, at the HBPoS at the Woodlands Unit in Suffolk, patients had no direct access to outside space and fresh air which was not in line with the Mental Health Act Code of Practice

The layout in the health-based places of safety (HBPoS) allowed staff to observe all areas. There was closed-circuit television (CCTV) which allowed staff to observe internal and external patient areas discreetly. CCTV had privacy blackspots on bathroom areas, though staff could observe patients in the bathroom with their consent when there was an identified risk associated with them being left there alone.

There were no potential ligature anchor points, and HBPoS had a ligature risk assessment and heat map in place.

However, at the HBPoS at the Woodlands Unit in Suffolk, patients had no direct access to outside space and fresh air which was not in line with the Mental Health Act Code of Practice. The service provided evidence that work was due start in November 2025 and be completed by January 2026 to install mechanical ventilation and an access door leading to a protected external courtyard space. This was added to the risk register for the service in March 2025.

At Hellesdon Hospital in Norwich, the HBPoS was in a temporary location whilst building work was underway to ensure the usual site was suitable. An environmental risk assessment had been completed for the temporary location and staffing establishment increased as it was not directly adjacent to a ward. The service had identified risks around unauthorised access to roof spaces in temporary location and acted to reduce this risk by installing roof protection and increasing security patrols. The temporary location had previously been a seclusion area and provided a suitable environment with access to outside space.

All HBPoS we visited were spacious, allowing room for patients to move around and for safe use of physical interventions, when necessary.

Staff had easy access to alarms including wearing personal alarms and lone worker devices.

Staff did regular risk assessments of the care environment, and all buildings had a local site-specific risk assessment. We reviewed the site-specific risk assessment for the Weavers Centre and Northgate Hospital. Relevant environmental risks were identified alongside actions to control the risk.

Where premises were shared with other services and teams, staff were given a safe premises plan which included general building information, ligature risk assessment and cutter guidelines, security guidelines, fire procedures and first aid and infection control guidance.

People who used services told us locations they attended to receive care and treatment were suitable and in a good state of repair.

Some HBPoS and CRHT teams were located next to inpatient settings, and all these had a ligature risk assessment, carried out as a yearly audit on the trust online audit system.

Consultation rooms used to meet people who used services were secure, suitably furnished and had sufficient seating.

Clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly. Staff checked resuscitation equipment daily using an online system, which alerted managers by email if the check had not been carried out.

The service did not always make sure there were enough staff.However, staff completed mandatory training. The service made sure staff received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

At the end of April 2025, there were 51.42 whole time equivalent (WTE) vacancies across all CRHT and 111 teams and across all roles including administration staff, therapy staff and doctors. Following our inspection, the service provided information to show the number of vacancies had reduced to 30.22 WTE.

East Suffolk CRHT now had 4 WTE vacancies for band 6 staff and 1 band 7 vacancy, which was held for a trainee to finish their cognitive behavioural therapy (CBT) training.

In West Suffolk CRHT the team had an additional band 4 psychologist to the staffing establishment. The team were reviewing the band 3 and band 5 vacancies to improve skill mix and create a further band 6 post.

In Central Norfolk CRHT there were now no vacancies, and the team recruited 2 nurse consultants following our inspection.

In Great Yarmouth and Waveney CRHT there were 1.25 WTE band 6 and 2 WTE band 5 vacancies. The service had plans to fill the band 8 vacancy. They had carried out a review of medical staffing and had a consultant and speciality doctor in place, with a further speciality doctor for the ward, which staffed the HBPoS, due to start in August 2025.

Managers had reviewed skill mix within the teams and were using posts creatively to fill gaps in staffing. For example, in East Suffolk CRHT band 3 vacancies had been changed to create 4 assistant practitioner roles at band 4 which were being advertised.

At West Suffolk CRHT, Suffolk 111 team and West Norfolk CRHT the number of vacancies had fallen from April 2024. There was adequate medical cover across the CRHTs, however Great Yarmouth and Waveney CRHT had a long-standing vacancy for a consultant psychiatrist. Managers told us this had recently been recruited to. Following our inspection, the service confirmed recruitment had been successful with a consultant due to start in August 2025.

Managers told us there was ongoing recruitment and new staff were due to start. At Central Norfolk CRHT, 15 new staff had recently been recruited and only 2 vacancies remained. Managers described work to improve recruitment and attract staff such as changes to the job advert and working with local universities. They also described realigning the workforce across the team, for example by creating band 4 and 5 positions so they could ‘grow their own’ staff and provide development opportunities.

Staffing issues were reflected in the service risk register for some services and actions taken to mitigate the risk. In East Suffolk, staffing was added to the risk register in March 2024. In Great Yarmouth and Waveney risk related to staffing levels was added to the risk register in March 2019. In West Norfolk, staffing was added to the risk register in July 2023.

The crisis transformation programme had recognised differences in staffing provision and make up across crisis teams and was looking at capacity data to redesign the workforce structures across CRHT teams.

In February 2025, 3 teams were above the trust target of 4.91% for sickness absence. These were:

• Norfolk 111 service at 13%
• East Suffolk CRHT at 8%
• West Norfolk CRHT at 8%

At our last inspection, only Great Yarmouth and Waveney team was below the trust target of 15% for staff turnover. In February 2025, the staff turnover rate was below the trust target in all teams except East Suffolk CRHT which was 19.5%. Though this was an improvement from our previous inspection when East Suffolk CRHT turnover rate was 24%.

When necessary, managers deployed agency and bank nursing staff to maintain safe staffing levels. Managers gave all temporary, agency and bank staff a local induction. Whenever possible, the service used long-term agency staff who were familiar with the service.

All new staff received a trust-wide and local induction, with a workplace induction checklist to complete within the first 4 weeks of starting work. Staff starting in a managerial role completed an additional leadership induction. Staff in the 111 service completed an extensive induction pack which had to be signed off by senior staff before a new staff member could work unsupervised.

However, between January 2025 and March 2025 there were 10 unfilled shifts due to sickness absence and 94 unfilled shifts due to vacancies across all CRHT teams. There were 6 unfilled shifts due to sickness and 44 unfilled shifts due to vacancies in central Norfolk health-based place of safety (HBPoS) for the same period. The service was not able to provide fill rates for the other HBPoS as these were staffed from within ward staffing establishment.

Following our last inspection, in September 2022 we told the service it must ensure there are enough staff to meet the needs of the service including assessing emergency referrals within the 4-hour target. Central Norfolk had one of the highest number of vacancies and only achieved 31% of referrals assessed within 4 hours. However, other teams with high vacancies such as East Suffolk and Great Yarmouth and Waveney did achieve better performance at 83% and 89% respectively. Managers told us the main impact of staffing pressures was on CRHT team capacity to assertively work with staff and patients in reach on wards to facilitate discharge.

We raised concerns about staffing levels during our inspection. The service told us they were working to attract people to work at the trust and they used a risk management approach to ensure clinical services were supported. They told us one aim of the current crisis transformation programme would be to have stronger integration between inpatient services and community services.

Mandatory training was comprehensive and met the needs of staff and people who used services. Staff in the CRHT teams mostly completed mandatory training, meeting the trust target of 85% in all topics. However, in West Norfolk CRHT 9 out of 17 staff had completed basic life support resus level 2 (BLS) which was 53%. In South East Suffolk CRHT compliance was 50% but only 2 staff were required to complete BLS training. In Great Yarmouth and Waveney 15 out of 22 staff had completed BLS training, 68%.Following our inspection, the service provided information that showed compliance had improved in 78% in West Norfolk CRHT, 85% in East Suffolk CMHT and 96% in Great Yarmouth and Waveney CRHT. The service had strengthened its approach to delivering BLS training. Staff could access a half day course ran by the ambulance service or a suite of training products which included online training, simulation training and mannequins and was available 24 hours a day 7 days a week

Managers provided supervision (meetings to discuss case management, to reflect on and learn from practice, and for personal support and professional development) to staff. Compliance with supervision met the trust target of 85% across all CRHT teams.

Managers supported staff to develop and gave them an annual appraisal of their work. Some support workers had been supported to develop to become senior support workers or into nursing through apprenticeships.

Managers identified the learning needs of staff and provided them with opportunities to develop their skills and knowledge. Staff told us they had received coaching and leadership training.

The service had 1 peer support worker at the HBPoS at Wedgwood House, West Suffolk. Peer support workers arepeople who use their lived experience of mental health problems to support others.

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 and reception and waiting areas at the locations we visited. All were visibly clean and tidy. Staff used ‘I am clean’ stickers to indicate when items and equipment had been cleaned and were ready for use.

Clinic rooms had suitable facilities for staff to wash their hands and had personal protective equipment available for staff to use.

Cleaning records were up to date and demonstrated all areas were cleaned regularly. In the health-based place of safety (HBPoS) at Hellesdon Hospital, Norwich the sink in the clinic room self-flushed regularly to prevent the spread of legionella.

The service had appropriate policy and guidance for staff to follow in relation to preventing and controlling infections. This included ‘bare below elbow’ guidance and posters on correct hand washing technique.

The service had a clear policy on dress and appearance which outlined the appropriate work attire to meet infection prevention and control and health and safety standards.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

The service had systems and processes in place to support people who used services with their medicines. However, staff told us the electronic prescribing and medicines administration system (ePMA) did not align well with how the crisis teams operated. However, staff in local teams could access the relevant information from different sections of the electronic system.

Staff monitored people for their adherence to prescribed medicines and provided support with daily administration of medicines when necessary.

Medicines were well managed within the health-based places of safety (HBPoS). Staff told us they would ensure that people had access to their time critical medicines when in the HBPoS. In some clinic rooms there was a list of time critical medicines available to staff. Clerking and prescribing was carried out by the duty doctor shortly after admission.

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. In the HBPoS medicines reconciliation was completed when the patient was admitted to the unit. Staff within the service could access information on medicines prescribed by GPs and were aware of high risk medicines taken by people who used services.

We reviewed records and found that people who used services were actively involved in decisions about their care and treatment. The services effectively used the patient led outcomes scale, which supported people who used service led approaches to reviewing care and treatment. When new medicines were prescribed or treatment was changed, this information was shared with GPs.

Information about people who used services was stored in multiple sections of their electronic care records. This made it challenging for staff to find and review information they needed to support people who used services. Some teams utilised the SBAR (Situation, Background, Assessment, Recommendation) tool, which helped facilitate clearer and more concise information sharing.

Medicines were stored securely and staff had access to emergency medicines if required.