Norfolk and Suffolk NHS Foundation Trust

Ratings - Well-led

• Well-led Our assessments of NHS trusts now focus on leadership. We no longer rate trusts overall for their safety, effectiveness and responsiveness or how caring they are. We do still publish those ratings for the services they provide.

  Requires improvement

Our view of the service

Norfolk and Suffolk NHS Foundation Trust (NSFT) was formed on 1 January 2012 following a merger of Norfolk and Waveney NHS Foundation Trust and Suffolk Mental Health Partnership Trust. The Trust supports a population of around 1.6 million people and employs over 5000 staff. NSFT delivers specialist mental health services for children, adults, people with a learning disability and autistic people across a variety of inpatient, community and primary care settings. Teams work in geographic care groups with dedicated local clinical leadership teams across the following areas:

• West and south Norfolk
• North Norfolk and Norwich
• Great Yarmouth and Waveney
• West Suffolk
• East Suffolk

The main sites are at Hellesdon Hospital Norwich, Wedgwood House Bury St Edmunds and Woodlands Unit in Ipswich but staff are based in more than 50locations.

NSFT is part of 2 local integrated care systems (ICS), Norfolk and Waveney ICS and Suffolk and North East Essex ICS. In February 2025 NHS England confirmed that NSFT had been moved from NHS oversight framework segment 4 (mandated national intensive support) to segment 3 (mandated regional support and oversight). In line with this NSFT was removed from the Recovery Support Programme (RSP), formerly known as “special measures”.

In June 2025 the new NHS Oversight Framework 2025/26 was published. The new framework describes a consistent and transparent approach to assessing NHS trusts, ensuring public accountability for performance and providing a foundation for how NHS England works with systems and providers to support improvement. NHS England will use the performance assessment process to measure delivery against an agreed set of metrics. This will determine the segment score for each provider and identify where improvement is required. Providers are allocated a segment between 1 and 5, with organisations in segment 1 considered to be consistently high performing across all domains and those in segment 5 being the most challenged and lowest performing. Segmentation was published in September 2025 placing the trust in segment 4.

We undertook a trust level (well-led) assessment of the trust which included an onsite visit on 13-15 May 2025. We also held 18 staff focus groups on and off site and observed board and committee meetings between April and May 2025.We assessed all 8 of the quality statements in the well-led key question in this assessment.

The well-led review followed assessments of 2 of the trusts frontline service groups (assessment service groups - ASGs): community mental health services for adults and crisis services and health based places of safety. These assessments were completed as part of the CQC's Adult Community Mental Health Programme. This programme of inspections contributes to CQC's commitment to inspect the standard of care in community mental health services across the country. These assessments also took into account information of concern we had previously received about community services at the trust.

The assessments identified concerns that community teams did not always ensure medicines and treatments were safe and met people’s needs capacities and preferences and that people were not always involved in planning. . Within crisis services there were also concerns relating to the deployment of sufficient staff and assessing emergency referrals as well as access to outside space at one of the trust’s health based places of safety. However, significant improvements were also noted across both ASG’s compared to previous inspections, including around physical health needs, data and governance, mandatory training and telephone access to crisis services.

We identified areas for improvement across all 8 well-led quality statements. These areas were as follows:

• Whilst there had been an improvement in culture overall, there continued to be pockets of poor culture across the organisation and staff continued to report poor experiences of working at the trust. Ongoing workstreams need to be monitored to ensure there is continued and sustained improvement in culture and experiences of staff across the trust.
• Many staff we spoke with reported that senior leaders were not visible. Ongoing work needs to be done to ensure the programme of regular service visits results in greater visibility to staff working across the organisation.
• There wasn’t always a positive working relationship between the trust and its governors. Work was needed to ensure all governors felt confident and empowered to fulfil their roles.
• The trust had been through a period of prolonged instability within the executive leadership team. The board was now stable, but this stability needs to be maintained to continue to rebuild relationships and confidence in the trust both internally and externally.
• Some staff we spoke with still didn’t feel safe speaking up or confident that their concerns would be actioned. The trust must continue to rebuild confidence with staff, ensure freedom to speak up processes are effective and be able to clearly demonstrate it has acted on concerns.
• Further work needs to be done at the trust to understand the full impact and implications of ongoing issues relating to staff skills mix. The lack of reporting and escalation of this issue prior to its identification also needs to be understood.
• Staff continued to raise concerns about racial and disability discrimination at work and the trust’s commissioned workforce race equality report highlighted significant concerns around the experiences of Black, Asian and ethnic minority staff at the trust. The trust must ensure the recommendations from this report are prioritised and actioned to ensure significant improvements are seen and sustained.
• Mental Health Act data highlighted concerns surrounding ethnic minority over representation especially in relation to section 136 and the criminal justice pathway. Work must be done to understand the reasons for this and to take action to improve the experiences of patients from an ethnic minority.
• There was further work that needed to be done to understand and address health inequalities across the trust’s services. This had been identified by leadership at the trust who had started to implement positive changes
• There was limited medicines support available for community teams across the trust. Whilst there is an improvement plan in place, the trust needs to ensure this is effectively implemented.
• Responding to complaints was taking longer than the stated timescales. The trust was taking action, but the success of these interventions needed to be monitored to ensure it was sustained.
• PSIRF (Patient Safety Incident Response Framework) had been implemented at the trust, however we saw significant delays in completing patient safety investigations. The trust was aware of this and had an action plan in place, but the trust must ensure the necessary changes are made to reduce the timeframes for these investigations. The trust had also identified learning from these investigations as a priority and must continue to implement measures that drive changes in practice.

However, we also recognised significant positive change across the organisation and there were also positive findings across all quality statements. These were:

• Across our ASG assessments and this well led assessment it was been evident that there were passionate, hardworking staff who were very committed to the trust and the people they served. Staff also told us they felt services were improving.
• Recent substantive appointments to the board had given stability and brought experience from high performing organisations.
• There was greater visibility of local leadership and groups such as allied health professionals (AHP) had professional leadership in place. All leaders were supported with development opportunities.
• There had been a marked improvement in stakeholder relationships.
• The new governance structure provided a robust framework and there was a clear and improved line of site between ward and board. The creation of strategic clinical collaboratives will also ensure staff teams from across localities remain connected and encourage best practice.
• There was strong clinical leadership and prioritisation at board level and locality leadership structures also promoted clinical voice.
• There was integrated reporting system to ensure all deaths were appropriately recorded. This gave a robust foundation to ensure the trust could learn from deaths moving forwards.
• Co-production with people who use services and carers had been prioritised by the trust and we saw clear examples where lived experience had impacted positive change in services.
• The sustainability lead was passionate and showed innovative working that not only promoted sustainability but also a connection to the organisation’s purpose as a mental health trust. It was also clear the board was engaged with and promoting the sustainability agenda.
• The trust was working to address issues in relation to speaking up, including an opportunity to write directly to the chief executive. This route had seen early success, including a high proportion of staff using their own name when reporting, rather than highlighting concerns anonymously.

People's experience of this service

During our ASG assessments service users and carers fed back positively about the care they received and spoke highly of staff.

The 2024 community mental health survey had a response rate of 21% and showed the trust scored largely the same in comparison to other trusts, however there were some areas in which they scored worse. These related to discussions around medication, support meeting needs and being treated with dignity and respect.

A review of service user complaints highlighted delays in responding. At the point of onsite assessment 38% of complaints were classed as overdue, however this reflected an improving picture over the past 12 months. Our review of complaints also noted that whilst complaints were mostly dealt with effectively, there was some inconsistency in the quality of the response. However, the trust was aware of this and had introduced new processes designed at improving consistency in this area.

There had been a notable improvement in friends and family tests. Response rates had increased by around 50% with ratings of good or very good care improving by 33% over the last 2 years. Poor or very poor ratings had also seen a reduction of 57% in the same timeframe.

Co-production with people who use services and carers had become an area of focus for the trust. A good example of this was the co-production work done around the Rivers Centre, a new 3-ward inpatient unit at Hellesdon hospital. The trust had also created a service user council and had utilised service users in the creation of the new standard operating procedure (SOP) for the crisis care pathway.

As part of the assessment we held 2 focus groups with a local campaign group. This group, which contains current and previous service users, family and carers reported ongoing concerns regarding care, how complaints are dealt with alongside delays in receiving outcomes of investigations.

Feedback from local Healthwatch’s on people’s experiences was mixed, however feedback on staff culture was generally positive with staff noted to be kind, non-judgmental and genuinely invested in patients’ wellbeing. There was negative feedback around access to services and poor treatment outcomes. Generally, Healthwatch also described an improved relationship with the trust alongside greater openness and transparency.