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.

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.

This service scored 71 (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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The trust had a clinical strategy from 2024 to 2029 and various programmes of change such as the crisis transformation programme aligned with this. 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.

Staff we spoke with were aware of the crisis transformation programme and told us leaders from that programme had visited the service. Staff had the opportunity to contribute to discussions about the crisis transformation programme. For example, 1 member of staff attended a listening in action event about the transformation and told us they were encouraged to put ideas forward to develop the mission statement. However, some staff told us they did not feel fully informed about the changes to crisis services.

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

The trust’s senior leadership team had successfully communicated the organisation’s vision and values to the frontline staff in the service and staff could describe these and how they applied to their team.

Staff could explain how they were working to deliver high quality care within the budgets available. For example, a manager described how they were using different bands of nursing staff creatively to keep within budget whilst meeting the needs of people who used services.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. 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 visibility since the recent restructure. They now 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.

Local leaders were visible in the service and staff reported they were approachable and supportive. Staff gave examples of leaders responding when incidents were reported to ensure the welfare of staff.

Leaders and managers, we spoke with had a good understanding of the services they managed. They could clearly describe challenges the service faced and the actions they were taking action to address them. For example, managers and leaders were working together, and alongside staff and people who used services, to redesign the statement of purpose for crisis services.

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

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. A Freedom to Speak Up Guardian works alongside the trust’s senior leadership team to ensure staff have the capability to speak up effectively and are supported appropriately if they have concerns regarding patient care. The trust’s freedom to speak up policy followed expectations for NHS services and was available to staff on the intranet. Most staff said they would feel confident to raise concerns with local managers and leaders initially and felt they would be listened to and concerns dealt with.

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.

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.

The trust had a network of ‘inclusion champions’ who were based across the geographic footprint of the service. This meant staff had access to peers with additional training who could support them by signposting to support and could offer anti-racism and cultural transformation interventions.

The trust had analysed the results reported in the Workforce Disability Equality Standard (WDES) report for 2024 to 2025. The trust provided us with data for the whole trust, not just this specific service. From 2023 to 2024 12% of the workforce identified as having a disability which was an increase from the previous year, where 8% identified as having a disability. Forty-eight percent of staff who identified as having a long-lasting health condition believed the organisation provided equal opportunities for career progression compared to 56% of non-disabled staff. The trust had a mentoring and reverse mentoring scheme to address this and had introduced a disability passport. Reverse mentoringinvolves 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 had analysed the results reported in the Workforce Race Equality Standard (WRES) report for 2024 to 2025. The trust provided us with data for the whole organisation.. The trust had acted on areas for improvement by ensuring recruitment panels for roles at senior leadership roles reflected the diversity of all stakeholders. 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.

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.

Governance for the mental health crisis services and health-based places of safety at the trust was generally good. The service had clear responsibilities, roles, systems of accountability and good governance. They acted on the best information about risk, performance and outcomes, and shared 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. Manager told us the daily locality flow meeting was useful to escalate immediate concerns and had the right people there to respond to and action concerns. 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 must be discussed at a ward, 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, including associate directors of nursing, associate medical directors, associate directors of psychology, associate directors of operations and business support managers. We reviewed minutes of these meetings from January 2025 to March 2025. They 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. Feedback from the locality safety meeting and locality service user and carer council was fed into the locality management group.

Senior clinical and operational leads attended weekly locality safety meetings. We reviewed minutes of these meetings from January 2025 to March 2025. They followed a set agenda which included reviews of patient safety incidents and learning, learning from deaths, urgent safety escalations and learning from complaints, actions from previous meetings were reviewed. The format of meetings was the same across all localities.

Staff maintained and had access to the risk register at locality level. Staff concerns matched those on the risk register and issues we found during the inspection were also reflected on the risk register. For example, risks related to staffing deficits in the West Suffolk CRHT team were recorded on the risk register. The register included controls in place, any gaps, actions to mitigate risk and a risk owner.

Staff had access to the equipment and information technology needed to do their work. Although we found the electronic care record system was fragmented and hard to navigate, staff were able to navigate it to access the information they needed to provide safe care. The trust provided evidence of a plan to implement a new electronic patient record system, which was in its early stages.

Issues with the system meant the information governance systems mostly included the confidentiality of care records. However, in 2 teams we saw staff keeping detailed electronic handover records which included confidential individual information, the information governance process for this record was not clear. This meant there was a risk that patient sensitive information may recorded in multiple places unnecessarily. We raised this with managers during our inspection who took immediate action to contact the trust information governance team and enacted a process to ensure the records were securely maintained until destroyed to meet information governance requirements.

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 patient care. Staff undertook audits, which were recorded using an online system. For example, we were shown data which was collected weekly to examine any gatekeeping breaches. Gatekeeping was when staff in CRHT teams provided care and treatment to someone waiting for an inpatient bed. Managers explained how the data was examined to ensure quality and safety of care was not compromised and correct data was reported to commissioners.

The service understood their duty to collaborate and work in partnership. They shared information and learning with partners and collaborated for improvement.

The service held regular meetings with external partners to ensure safe systems of care were established. For example, the Norfolk and Waveney crisis pathway meeting was a system wide collaborative meeting run by the service, in collaboration with the integrated care board (ICB). Partners met monthly to examine the utilisation data, review demand and capacity, and areas of improvement, and to escalate where gaps were identified.

The service reported any patient safety incidents to the ICB on a weekly basis and met with them each month to discuss any incidents in detail.

The service commissioned an external review to assess how collaboratively its staff worked with the police in light of implementation of the right care, right person approach. The reports published in December 2024 looked at the health-based place of safety pathway and found there were challenges of access to a health-based place of safety, in line with the national picture. It found the average time a police officer spent in an emergency department with a patient due to an HBPoS being unavailable by for patients under section 136 was 7 hours. The Mental Health Act 1983; Code of Practice states ‘Healthcare staff, including ambulance staff, should take responsibility for the person as soon as possible, including preventing the person from absconding before the assessment can be carried out. The police officer should not be expected to remain until the assessment is completed; the officer should be able to leave when the situation is agreed to be safe for the patient and healthcare staff.’

Directorate leaders engaged with external stakeholders, such as commissioners and Healthwatch. Managers in the 111 service had worked with local commissioners to develop ways to address the demand made by frequent callers. They developed frequent caller plans with external services and teams within the trust.

The service signed up to the East of England’s regional information sharing agreement for direct care. This meant that staff could immediately share appropriate and proportionate information with professional colleagues. The agreement was included in mandatory staff information governance training.

The service also had appropriate information sharing agreements which allowed staff to share appropriate information with a range of statutory and voluntary sector partners such as the police, schools, the Samaritans and the Alzheimer’s Society.

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 contributed to safe, effective practice and research.

Where teams were piloting innovative and new approaches, learning was used to develop the service across all areas. For example, in the Central Norfolk team, feedback from the pilot of an autism and autistic spectrum disorder team for people who used the CRHT services was evaluated to feed into the wider crisis pathway transformation programme.

Staff were given the time and support to provide their ideas for improving the service and coming up with innovative ideas and this led to changes. For example, managers were working with the Integrated Care Board (ICB) and a local voluntary sector agency to improve use of recovery houses and had a standard operating procedure for referral and discharge. The work was linking to the crisis pathway transformation programme which was ongoing.

Staff used quality improvement methods and knew how to apply them. Staff in the service used the ‘plan, do, study act’ cycle to implement improvement projects. Innovations such as development of a joint working protocol between CRHT teams and community teams in Suffolk were being rolled out across the service.

Staff responsibilities for learning from patient safety incidents were clearly set out in the patient incident safety response plan (PSIRP).