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
• Environmental sustainability – sustainable development

We have not awarded this service a score for Well-led.

Find out about when we will not publish a key question score and what we look at when we assess Well-led.

The trust’s vision was ‘Improving together to provide safer, kinder and better services’. The vision also reflected a commitment to timely access to services and compassionate care. The trust had a co-produced values and behaviours framework. These values were: we are a team, we are accountable, we learn and improve and we are kind. These were known as ‘Together we TALK’.

The trust launched a new strategy in May 2024 due to run until 2029. This strategy focussed on 4 main priorities, but also driving change through 12 large scale improvement and transformation programmes. The four strategic priorities were improving health, improving care, improving culture and improving value. The 12 large scale change programmes were aligned to the 4 main priorities and included clinical transformation, listening into action (LiA) and efficiency value and improvement (EVI) programme.

The strategic priorities reflected insight gained through significant engagement work with trust staff, external stakeholders and people who use services. The trust strategy was supported by a number of enabling strategies and was also aligned with the shared vision and strategy for the local integrated care systems. Stakeholders fed back positively about the strategy and that it felt lived.

Significant large scale change had already been delivered within the trust over the last year. There had been a recent restructure into locality leadership in line with ‘place’ which was brought in at the end of 2024, with dedicated clinical leadership delivering care across 5 geographic care groups. A new governance framework had been implemented alongside this.

Medicines Optimisation (MO) was a priority for the trust. A Medicines Optimisation Improvement Plan was in place and progress has been made in areas such as inpatient medicines management, valproate safety, when required medicines (PRN) and medicines procurement and this was reflected in the current medicines policy. The team were currently developing clinical pharmacy standards. A formal MO strategy was planned to align with the upcoming NHS 10-year plan.

Leaders knew the trust vision and values and were clear on their strategic objectives moving forwards. Board priorities were clearly aligned to strategic objectives, were descriptive and had measurable outcomes which were monitored. Whilst implementation of the new strategy was relatively recent, leaders were already able to identify and describe how the implementation of the strategy was leading to meaningful and measurable change within the trust, and what this change would look like moving forwards.

Whilst a small number of staff recognised there had been service visits from senior leaders, most frontline staff reported a lack of visibility of or engagement with senior leadership. However, staff were positive about the accessibility of the local leadership team. The trust had a programme of regular service visits carried out by executive and non-executive directors, however this had not yet significantly improved visibility to staff teams. The trusts footprint also covered a large geography including stand-alone units, adding to the challenge of improving visibility.

We undertook 18 focus groups speaking to around 140 staff. Staff reported that there continued to be pockets of poor culture across the organisation. Staff raised that the realignment into locality structures had resulted in some staff having to reapply for their jobs and reported communication around this had at times been poor and had significantly impacted morale. Staff also reported this process had caused significant stress.

The board acknowledged that historically poor culture had been a significant issue at the trust and that there was ongoing work still needed. There was also an acknowledgment that equality and diversity had historically not been prioritised and that there had been a lack of commitment by leaders to promote inclusion. Significant work still needed to be done in this area. However, improving culture was a strategic priority at the trust and the current board was showing a renewed commitment to improving the experiences of staff from an ethnic minority background alongside the culture of the organisation as a whole.

The trust had processes to identify and address behaviours that were inconsistent with the values of the NHS. The trust’s values (Together we TALK) had a behavioural framework aligned to them which had been co-produced with staff through the ‘Big conversation’ and Listening into Action (LiA) engagement programmes. Some staff raised concerns about the length of time staff disciplinary processes took. A review of current disciplinaries at the point of onsite inspection showed the average length of all open cases to be 145 days. Whilst disciplinary investigations appeared to have been effectively carried out, there were significant delays noted in the processing of some. However, in some instances this was also due to external factors.

The staff survey results indicated that there was more work needed to ensure staff were engaged and had positive working experiences. In the 2024 staff survey NSFT scored lowest nationally for several themes when compared with other similar trusts, especially regarding issues around culture, staff morale, teamwork, staff engagement, and acting on concerns. Staff from ethnic minority backgrounds as well as staff with a long-term condition or illness reported higher rates of harassment and bullying (including from patients, colleagues, and/or management) when compared to the national average.

The trust acknowledged these results and had analysed them alongside Listening into Action (LiA) feedback received through trust ‘pulse check’ surveys, identifying 5 key themes. These themes were aligned with the trusts’ strategic priorities in relation to improving culture and had been passed on to LiA teams to take forward the actions. Alongside this the trust had a newly designed staff survey dashboard which made the data accessible at locality level. This allowed locality leadership to understand their service level data and to co-produce plans to improve the experiences of staff.

Some of the trust governors reported that there had historically been a culture of defensiveness around their engagement and a lack of information had been shared with them.. They also reported that the significant changes within the trust leadership had made it difficult to build relationships with and confidence in the executive team. Some governors felt they were discouraged from asking questions and therefore did not feel confident in their ability to hold non-executive directors (NEDs) to account. Governors also reported that they felt like their leadership was very one directional and lacked collaboration. They also reported a sense of disconnect currently between NEDs and governors. However, with the new locality leadership structures governors and NEDs were due to be aligned to specific localities and there was hope from governors that this might help to improve relationships.

Feedback from system partners commented on the significant changes in the executive leadership team over the past few years and the instability this had caused in building relationships and making delivery progress. However, it was noted that the new leadership team had brought stability and experience and partners acknowledged an intent from the trust to move forward culturally and improve partnership working. Engagement from the new locality leadership was also noted to be positive.

We observed the trust’s board meetings, attended several governance meetings and reviewed minutes. These included the sub-committees of the board. In all meetings we saw leaders acting with integrity, credibility and respect. The trust supported accessibility by allowing attendance remotely where appropriate. They also rotated the locations of board meetings through different sites across the trusts footprint to support attendance. Board papers were available in advance and following meetings subtitled recordings of the meetings could be accessed. The trust had also produced a glossary which was available alongside their board papers providing a full explanation of some of the terms used.

The trust’s board comprised of 8 executive directors including the chief executive officer (CEO) although at the time of inspection one post was vacant. There were 9 non-executive directors including the trust’s chair. The executive team had individual portfolios covering all the necessary areas of work for the trust. These included patient safety, quality of care, risk management, performance, finance and organisational development. Some of the executive directors had very large portfolios alongside significant line management responsibilities, but reported they felt confident that they had the necessary support to enable them to have the capacity for these roles.

The trust had historically had significant instability in its’ leadership team. The trust had had 9 CEO’s within 10 years as well as interim chairs and a changing executive team. The chief nurse, chief medical officer and chief transformation officer had all joined the trust in the last 18 months. The CEO had been appointed to a substantive post in December 2024 having been interim for a year prior. At the time of inspection there was also an interim chief people officer with a substantive due to start in June 2025. The chief delivery officer role had also not yet been appointed to. However, it was recognised that these recent substantive appointments to the board had brought stability and also significant experience from high performing organisations. There had also been changes in the non-executive directors with the chair ensuring all had an appropriate range of skills and experience.

There was a board development plan in place with 2 board development sessions planned for 2025. There were also 5 board strategy sessions planned for the year. The content of these sessions was appropriate with topics such as health inequalities, research and innovation and patient safety incidence response framework (PSIRF).

Leaders could describe succession planning within the trust. This was an area the trust had previously not prioritised, and the current executive team had all been appointed externally. Recent work had been done around succession planning, improving internal talent management and development and retention of staff, and these areas were prioritised in the people and culture strategy. Further work needed to continue in this area to ensure a sustainable workforce.

The trust had a fit and proper person policy, and we found records to be in line with requirements. It was noted however that occupational health assessment was not routinely carried out by the trust as part of their fit and proper person check. However, following on from our onsite assessment the trust informed us that moving forwards executive directors would now be asked to complete an occupational health check in line with best practice.

There were 5 ‘place’ based locality care directorates in the trust, West and South Norfolk, North Norfolk and Norwich, Great Yarmouth and Waveney, West Suffolk and East Suffolk. Each locality had a triumvirate leadership structure with a medical director, director of nursing, and director of operations. There was also a director of psychology and principle allied health professional (AHP) within each. Each of the 5 localities provided inpatient, urgent, emergency and community mental health services. Specialist services were ‘hosted’ by different localities. Corporate services including finance and HR were in the process of being aligned to the localities. These structures were new to the trust having been only implemented at the end of 2024. However, feedback from staff was positive about these structures and about the accessibility of local leadership.

There was strong clinical leadership and prioritisation at board level and locality leadership structures also promoted clinical voice. There was a clinical strategy in place and clinical transformation was one of the large scale change programmes prioritised by the trust for 2025/26. Staff described local clinical leadership as supportive although staff from some specialist teams reported having lost specialist clinical leadership as part of the realignment into locality structures.

The current chief pharmacist joined from NHS England and brought national experience in medicines optimisation and system improvement. Although the post was not permanent at present, there were plans to recruit to the role following the trust corporate redesign and work was already underway to upskill the senior pharmacy team and embed improvements to continue the progress made so far. The Medicines Safety Officer (MSO) role had been vacant for over 18 months, which impacted the leadership in delivering the medicines safety agenda, but this has now been recruited to, with the new post holder due to start later this year.

The trust reported undertaking significant work to build stakeholder relationships and improve partnership working. Stakeholder feedback noted an increased openness from the trust and focus on improvement. It was noted that the recent restructure into a locality leadership model had impacted on the clarity of leadership and functioning of meetings and relationships over the past year, but that there was a clear aim to promote stronger relationships moving forwards.

The trust had a freedom to speak up (FTSU) policy which was due for review in June 2025. The trust had recently moved back to a fully internal freedom to speak up service from an external guardian service. There was a head of freedom to speak up who currently reported to the patient engagement lead. The trust had also recently recruited a FTSU manager and there were 14 speak up champions across all localities with 34 further staff members being trained. The trust had implemented a process whereby FTSU concerns were RAG rated determining how quickly local leaders must respond to them.

The latest FTSU up data from the trust showed that 187 cases were raised at the trust between April 2024 and March 2025. This sat in the middle of reporting numbers for similarly sized trusts in the East of England suggesting that at least some staff felt able to report concerns to the FTSU guardians. The trust also reported a marked increase in FTSU cases since the return to a fully internal FTSU guardian. The largest proportion of these related to inappropriate attitudes and behaviours.

The 2024 NHS Staff Survey showed that 50.87% of staff agreed with the statement ‘I feel safe to speak up about anything that concerns me in this organisation’. This was below the national average of 66.58% and was also a significant drop from the previous year’s score of 57.70%. The survey also showed that only 33.65% agree with the statement ‘If I spoke up about something that concerned me I am confident my organisation would address my concern’. This is below the national average of 54.93% and again had shown a decline from the previous score of 39.79%.

Staff reported that they all felt safe raising patient safety concerns to local managers and felt confident they would be acted on. There was less confidence about whether concerns were acted on when they were escalated further to senior management. Staff also reported less confidence in reporting concerns outside of patient safety such as concerns around behaviour. Staff reported incidences where senior leadership had not responded to concerns raised and this had undermined confidence in reporting. Leadership instability at the trust had further compounded this lack of confidence in reporting and action. Trust data showed cases that had been escalated via formal FTSU routes were being processed within appropriate timeframes, however this had not yet resulted in an increase in staff confidence. More time and ongoing work was needed to fully rebuild trust with staff and ensure they feel able to confidently raise concerns.

The CEO had also launched an initiative called ‘Dear Caroline’. This initiative allowed staff to escalate concerns directly using an online form. This aimed to provide solution focused responses to concerns raised. The process could be completed anonymously, but to date 75% of respondents had provided their name reflecting people felt safe to do so.

The trust monitored equality, diversity and inclusion in their workforce in line with the NHS Workforce Race Equality Standard (WRES).

As part of the NHS Staff Survey, the Workforce Race Equality Standard (WRES) highlights potential differences between the experiences of white staff and staff from all other ethnic groups combined (AOEGC).

Results from the 2024 NHS Staff Survey showed that staff from AOEGC experienced harassment and bullying at a higher rate than other white employees (including patients, other members of staff, as well as managers and team leaders), but also at a higher rate than the national average. Additionally, less staff from AOEGC believed their organisation provided equal opportunities for career progression or promotion compared to white staff at the trust (who answered the same question). The response rate from both white and AOEGC staff was lower than the national average, highlighting a concern around career progression. Although WRES data focuses on race and ethnicity, the results from white staff at the trust also scored worse than the national average in all criteria, especially on the question about equal opportunities for career progression. Whilst these results do not invalidate the experiences of staff from AOEGC, they may also suggest that this could be a trust-wide issue.

For 2023/2024, the WRES workforce indicators showed that ethnic diversity in staff groups was lower than the national average (13.5% vs 26.4%). However, this is significantly higher than the proportion of ethnic minorities in the Norfolk and Suffolk area served by the trust, Norfolk’s population is 96.5% white and Suffolk 93.1%. White staff represented 87.6% of staff at non-clinical management grades at band 8a or above. In clinical posts the percentage was slightly higher with white staff representing 90.2% at grades 8a or above, although greater diversity was seen in lower bands. The greatest diversity was seen in medical staff where white staff make up 49.5% of the total staff group. Data for 2024 showed White staff are 2.17 times more likely to be appointed from shortlisting compared to staff from any other ethnic group. The trust had a WRES action plan aimed at tackling these inequalities which included actions such as diverse recruitment panels, implementing an ICS debiasing tool kit, introducing a mentoring programme and additional anti racism training for staff.

According to the 2024 NHS Staff Survey, the trust’s results were worse than the national average in all 7 Workforce Disability Equality Standard (WDES) metrics. The responses highlight overwhelmingly negative experiences for disabled staff and/or those with a long-term condition who work at the trust. These include higher rates of harassment and bullying (including patients, other staff, and managers team leaders), higher rates of pressure from managers to come to work, and lower job satisfaction. Much like the WRES, all staff (both disabled and not) who responded seemed less confident about equal career progression than the average percentage of staff with a long-term condition or illness nationally (staff with a long-term condition or illness scored lowest in this metric, with 44.48%).

In 2024 the trust separately commissioned a workforce race equality report to gain a deeper understanding of the experiences of Black, Asian and ethnic minority staff at the trust which published in May 2025. This report highlighted that in recruitment processes between 2001 and 2024 74% of all non-medical applicants were from a Black, Asian or minority ethnic background, but only made up 21% of all appointments. Data on formal disciplinary processes for the same period showed that ethnic minority staff made up 22% of the total disciplinary actions, significantly higher than the overall representation in the workforce of 13.5%. It also noted that 26.9 % of black staff that enter the disciplinary process were dismissed, this was significantly higher than 16.7% for Asian staff and 12.7% for white staff.

A series of semi-structured interviews with staff were also undertaken as part of the review process. These highlighted feelings of despondency and depression in staff from Black, Asian and minority ethnic backgrounds due to a lack of action and change in the organisation. Staff felt that leaders had historically shown a disregard or disinterest in race inequality in the organisation and that for real change to happen board leaders would need to show race was a priority. There were also concerns raised around the transparency of recruitment processes and diversity of the interview panel. Culture was also raised as a concern with staff reporting that racism, bullying and harassment were commonly and widely experienced.

The report did however acknowledge that the current CEO and chair are clear in their determination to make the necessary changes with regards to race and have made a commitment to ensure there is action on the issue in the trust.

The trust had acknowledged the findings of the report. Commissioning such a report has created significant insight into the challenges experienced at the trust by Black, Asian and minority ethnic staff. Following on from our inspection, the trust informed us that is had agreed the strategic plan to deliver the recommendations made by the report. However, this has yet to have an impact on the experiences of black and minority ethnic staff.

The trust had an anti-racism learning programme which had been co-developed with NHS England (NHSE). So far 8 sessions had been run with engagement from around 1300 staff. There were also additional resources available on the trust intranet. The trust also had an LiA workstream looking at workplace equity and inclusivity called ‘United to Combat Racism’. The trust held a race conference in May 2025 attended by 250 members of staff. This conference publicly discussed the 6 key themes from the workforce race equality report. The trust also informed us that 3 members of staff had been shortlisted for the BAME Health and Care Awards 2025.

The Patient and Carer Race Equality Framework (PCREF) is a new mandatory race equity and accountability framework for mental health trusts in England. The purpose of PCREF is to support trusts to improve racial inequalities in access, experience and outcomes of mental health care. All mental health providers were expected the implement the framework by March 2025. The trust had signed off their PCREF plan in March 2025 but the framework was not yet embedded at the time of inspection. However, their plan was detailed and the trust was working on steps to full implementation.

Both WRES and PCREF had recently been written in to key competencies for all staff at grade 8a and above, including directors.

The trust monitored gender pay gaps and the board received and annual report. The median gender pay gap in 2024 showed women earning 10.41% less than men. This is higher than the median gender pay gap for the NHS as a whole which was recorded as 8.83%. The trust had developed an action plan to better understand the reasons for this for the gap and to put in place measures, including training and support, to address issues identified.

Review of data relating to the use of the Mental Health Act (MHA) revealed ethnic minority over-representation compared to the national picture; especially with regard to section 136 of the MHA and the criminal justice pathway. There had been no unjustifiable detentions, but data highlighted that earlier interventions were needed.

Staff networks had been built to promote equality, diversity and inclusion. The trust had 7 staff networks. Networks had executive sponsors and dedicated budgets and chairs had protected time to deliver their roles. However, members reported with the significant leadership change there had also been significant change with executive and non-executive sponsors, and some had experienced delays in realignment of sponsors to their networks.

Networks delivered significant positive benefit to staff. Networks were visible in highlighting concerns, providing support to staff and training to the organisation. The women’s network had gained ‘Menopause Friendly’ accreditation for the trust. NSFT are the first mental health trust in the country to be awarded this accreditation, and the trust also received a highly commended award at the national 2024 Menopause Friendly Awards.

Changes had recently been made to staff network groups to ensure consistency. Members reported that whilst gaining consistency was a positive, the way it had been introduced was not well communicated and networks felt they had lost some autonomy. There had also been an inclusion reporting framework recently introduced, where staff networks reported each meeting to the inclusion council. Network members were currently unclear of the impact of this due to its recent introduction. After the inspection the trust told us that they had taken action to respond to the feedback from staff networks.

There were 7 subcommittees of the board. These were remuneration, audit and risk, performance and finance, people and culture, quality, mental health legislation, and charity. Key risks and updates were shared in a report from each sub-committee to the board. The non-executive directors (NEDs) were aligned to the sub-committees and also attended meetings which they did not chair to get a broader understanding of the work of the trust.

In 2024 the board assurance framework (BAF) was redeveloped to align with the strategic and improvement priorities of the trust. During this process the trusts’ risk appetite statement was also refreshed. The BAF contained 15 principal risks which were also the corporate risk register. Risks also had full alignment to the trusts 4 strategic priorities. The BAF was a live and dynamic document that was updated every month.

Principal risks were discussed with executive leads every 4-6 weeks, reported and discussed through a Trust Management Team (TMT) subgroup monthly with the relevant operational risks and then reported through to board and relevant committee meeting. All recorded risks included the dates added and the executive owner and described current actions in place to mitigate.

Operational risks were held within wards, teams and corporate departments. Any risks rated 15 or above were reported to the relevant subgroup of the TMT each month. These were then aligned to the TMT subgroup where action could be taken, aligned to a committee of the board where the impact of risk could be felt, aligned to a principal risk in the BAF and aligned to a risk appetite category. An assurance report was produced 6 monthly detailing the ongoing management of operational risks.

The trust currently considered their top 3 risks to be quality of care including demand (waiting lists) and estates, staffing and culture and finance. Senior leaders were able to clearly describe the organisations’ top risks. Additional training on the management of risk was also being provided to locality directors.

With the alignment into locality leadership teams a new governance structure had recently been implemented. The new structure was robust with clear lines of escalation from ward to board. A ‘rhythm of the week’ had been implemented creating a regular pattern of meetings. Localities held their own individual weekly meetings with teams where service concerns could be reported and discussed. On a weekly basis there was also a Patient Safety Group attended by all locality leadership teams which highlighted patient safety concerns and quality issues. This was chaired by the Chief Nurse. There was also a weekly Business Delivery Group meeting focussing on performance chaired by the Chief Operating Officer (COO). On a monthly basis all the localities came together for the Trust Management team meeting which was chaired by the CEO. These meetings allowed prompt escalation of concerns directly to the executive team as well sharing of information across the localities and highlighted areas of immediate learning.

Six clinical collaboratives were being created as part of the trust’s clinical transformation programme. These were children and young people, adult inpatient, adult community, older people, crisis and urgent care and learning disabilities and neurodevelopmental disorders. Specialised services were connecting within the East of England Provider collaborative. These clinical collaboratives will bring together staff from teams across all localities with the aim of strengthening clinical leadership within these groups, reducing variations in care, encouraging best practice and sharing learning. Although these were not in place at the time of the inspection there was an implementation plan in place and clinical chairs for the collaboratives were being recruited to.

The trust had a process for gathering, analysing and escalating performance data in an accessible format to the board consistently and regularly. The trust produced comprehensive integrated quality and performance reports (IQPR). These included a wealth of data such as waiting times, out of area placements, complaints and patient safety incidents. Data was presented clearly and related back to the individual directorates. Future expectations on trajectory were clear and those responsible for monitoring were clearly identified. Data was presented in a way that trends over time were easily identifiable. Where appropriate benchmarking was also included. IQPR reports were also presented in alignment to strategic priorities. Individual localities had a standardised reporting pack mirroring the one produced for the board, including IQPR, improving the flow of information from ward to board. Non-executive directors (NEDs) generally reported a picture of improving data quality but reported data in committee papers could be out of date.

Feedback from system partners noted the trusts recognition of the need to strengthen its’ clinical governance and quality oversight and the steps it had taken to do so. However, some partners also fed back a lack of clarity around specific roles and escalation routes within new structures.

The trust had a guardian of safe working hours and reports were delivered to the board quarterly. Currently at the trust working practices for trainees continued to be safe. The trust had arrangements in place to complete medical appraisals and revalidation. There was a well-developed Junior Doctors Forum, which was supported by union and human resources (HR) attendance.

During our assessment of frontline services staffing was raised as an area of concern, particularly within crisis services. Staff recruitment and retention impacting on the consistency of staffing was identified as a significant risk during the inspection. However, 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 Crisis Resolution and Home Treatment (CRHT) teams. The trust also identified staffing as one of its primary risks on the BAF and mitigations were in place.

The latest subcommittee papers showed turnover as 11%; vacancies at 9%; and sickness as 5%. Over the past 12 months there had been a significant increase in the number of substantive staff working at the trust. The trust had ongoing initiatives in place to support the recruitment and retention for staff including a vacancy control and fair recruitment programme, values-based recruitment, an exit interview dashboard, absence management programme, coordinated recruitment programmes and commitment to recruit all student nurses educated through local universities.

On a recent service visit the chief nurse had uncovered an issue at the trust surrounding the skills mix of staff. This had highlighted that in some inpatient areas some shifts had been staffed with only Registered General Adult (RGA) nurses and no Registered Mental Health (RMN) or Registered Learning Disability (RNLD) nurses were on shift. The trust took prompt action to understand the scale of the problem and to ensure wards were safely staffed and was undertaking a clinical harm review. Staff impacted were regularly communicated with through weekly webinars held by the chief nurse and 1:1 was support was being offered by line managers. However, staff reported it had been a challenging period, with RGA’s reporting feeling undervalued and RMN’s reporting being impacted by increased workload. Both groups also raised concerns about increased use of agency staff and the impact this had on patient care and continuity. There was further work ongoing at the trust to understand the full impact of and mitigation of this issue.

Medicines Optimisation is overseen through the Medicines Optimisation Group (MOG), which meets monthly and reports into the Quality Group. Whilst 96% of inpatients received a medicines reconciliation in 2024, this was not replicated in community settings. A new standard operating procedure (SOP) for medicines reconciliation had been drafted to support consistent practice and will be embedded to improve oversight across the trust. This plan features improving pharmacy support to community mental health services as there was only direct support to 3 teams out of 23. Following on from our inspection the trust informed us that that had significant clinical pharmacy support guiding their community transformation and also informed us of plans to implement a pharmacy business partner at each locality following on from their corporate redesign.

Whilst the Medicines Safety Officer (MSO) role was vacant the medicines safety agenda was led by a medicines safety pharmacist who conducted thematic reviews from reported incidents and reported monthly to the MOG. Key areas of focus included insulin safety, wrong patient administration incidents and risks with prescribing and administration of PRN medicines. A trust-wide review of all medicines audits was undertaken which identified four additional areas of concern: construction and sizing of medicine cupboards and FP10 prescription management and usage. These have since been addressed by the trust. However, the High Dose Antipsychotic Therapy (HDAT) audit is only conducted across the inpatient units within the trust, therefore providing no oversight of use within the community.

A medicines management dashboard was now in place, which allowed oversight of missed and delayed doses of medicines. A working group was established and made recommendations in February 2025 to minimise delayed and omitted doses. Some had already been actioned, and other areas were currently being worked on including identifying critical and time-critical medicines.

There were arrangements in place to ensure that the trust discharged its specific powers and duties according to the provisions of the Mental Health Act 1983 (MHA). An acting head of mental health law was in place, there was also an executive lead who was the Medical Director for East Suffolk locality.

The Mental Health Legislation Group looked at the data gathered by compliance officers including manual audits. A data lead was also in place. The Mental Health Act Legislation Group took points of note onwards to the trust management team and the Mental Health Legislation Committee; both met bi-monthly. Oversight of mental health law had moved to the chief medical officer. A MHA Committee had recently been re-established which included representation from each locality and the Mental Health Legislation Group fed into this. Concerns raised in CQC Mental Health Act monitoring reports were responded to by the quality team. Concerns were reviewed, relevant meetings were arranged and action plans were produced to improve practice.

In Norfolk, there were 80 Approved Mental Health Professionals (AMHP) with 8 plus AMHPs rostered on duty each day. In Suffolk, there was a dedicated team of 9 full time equivalent AMHPs. There was an emergency duty team for out-of-hours cover on the evenings and weekends. The AMHP teams were provided by the local authority across both Norfolk and Suffolk. AMHP teams did not work with patients who lacked capacity to agree to the crisis service, which meant that they were often not able to provide input in accordance with the least restrictive principle.

Section 12 doctors were organised using the ‘solutions app’ for both Norfolk and Suffolk local authorities. The register of section 12 doctors was provided and updated by the Integrated Care Board (ICB). The 2 main issues regarding section 12 doctors were that most of them worked for the trust so they were not available for assessment under the MHA until after their shifts concluded. This impacted on the hours worked by the AMHPs.

The trust had arrangements in place to monitor its compliance with the Mental Health Units (Use of Force) Act which came into effect in 2022. The trust had a lead to oversee the work to monitor and reduce the use of restrictive interventions. In April 2025 the Trust’s Prevention and Management of Aggression (PMA) department had successfully earned accreditation for meeting the Restraint Reduction Network (RRN) training standards. In respect of Physical Intervention training, significant improvement had been made in the previous 12 months to reach training compliance of 85%.

Trust monitoring had shown a sustained reduction in restraints over time since 2024. This included a reduction in prone restraints linked to the introduction of Safety Pods. There was continued opportunity for further reduction with 4 trust wards members of the National Quality Improvement Programme delivering the Culture of Care standards within inpatient services. The next stage of work was enabling other wards to benefit from this learning.

There were processes to manage the financial resources and sustainability of the trust. The trust had a record of delivering its financial plans, albeit in recent years through the use of accumulated funds. For 2024-25 the Trust set and delivered a breakeven financial plan which it had achieved, including a cost improvement plan. For 2025-26 it was planning to break-even financially with cost improvements. However, the break-even position was being achieved in part by one-off savings. The trust estimated that it had an underlying deficit of around £15.4million going into 2025-26; and acknowledged that cash reserves were becoming depleted. The trust had an established efficiency, value and improvement (EVI) programme to monitor this.

At the time of the inspection the trust was planning to spend £8.6million in 2025-26 on improvements to its estates, equipment and digital capacity.

The Chief Financial Officer (CFO) had been in post around 2.5 years. He told us that he had developed effective working relationships with ICB and trust colleagues and this was evidenced by the capital expenditure flexibility that the trust had received in 2024-25 to complete its major capital project at the Hellesdon Rivers Centre.

The Chair roles of the trust’s committees were in the process of transfer, following a planned recruitment of new non-executive directors. The Performance and Finance committee Chair and the Chair of the Audit and Risk committee were both experienced non-executives with experience in finance. They each sat on both committees, providing continuity.

An external auditor had given favourable opinions on the Trust’s accounts for 2023-24. The audit of the 2025-26 accounts was in progress at the time of the inspection. We noted that the internal audit programme had slipped substantially, with final audits for the 2023-24 year being finalised in March 25; although we were reassured that sufficient fieldwork had been undertaken to allow the Head of Internal Audit to provide an opinion on the operation of internal controls. The trust told us that steps are being taken to increase assurance about internal audit performance.

The Trust had invested significantly in transformation programmes that it expected to improve both organisational culture and sustainable efficiency. It had set itself financial targets to increase the delivery of sustainable transformation that would reduce its underlying deficit. However, it recognised that its plans could be destabilised by inherent risks arising from pressures including staffing levels; out of area placements; and unbudgeted costs.

There was effective oversight of cybersecurity and information governance at the trust. Information governance was overseen by the information governance group. There had been no cybersecurity incidents recorded. An independent review of all 10 data security standards at the trust showed a high level of assurance across all 10 standards. The audit coverage was aligned to the mandated areas selected by NHS England for 2023-2024.

The trust had a digital strategy. One of its programmes focussed on updating the current Electronic Patient Record (EPR) system. The current system was an area of concern raised by staff during our assessment of frontline services. Other areas of focus included improving the digital literacy of staff and improving the quality and reliability of data.

The trust board had done significant work prioritising and strengthening its partnership working. Stakeholder feedback reported that the trust had a definite understanding in relation to the duty to collaborate and work in partnership. Stakeholders reported a much more open approach and greater understanding of working collaboratively to improve patient outcomes. They also reported that trust leads were now active members of partnership meetings and actively contributed. It was also noted that the trust and local leadership teams had reached out to primary care to improve relationships and partnership working which had previously been strained.It was reported that the trust was now increasingly seen as a credible partner.

However, some challenges were reported in maintaining consistent arrangements at multiagency meetings. One county council also reported that responses from the trust to safeguarding enquiries under Section 42 of the Care Act had been inconsistent and reported experiencing significant delays in obtaining information back from NSFT to inform enquiries. The information that is requested is often vital to analysing the risk posed to the person and others, therefore delays in sharing could lead to people being left at risk of harm. The relationship with NSFT’s safeguarding team was reported as good with consistent engagement and action being taken. However there appeared to be challenge holding internal teams to timeframes. After our inspection the trust informed us that they have introduced a senior post to oversee improvements in this area.

There were no longer any Section 75 agreements in place between the trust and the county councils. This has impacted the ability of staff to access records. There were 5 service level agreements in place for the general acute hospitals across the trust footprint and MHA administration support was provided. Local authorities reported that the trust demonstrated effective collaboration with the local authority and other healthcare providers to meet population needs, including actively engaging in its statutory Section 117 responsibilities.

Positive collaborative working was noted with the local police force regarding Right Care Right Person (RCRP), to ensure safety is maintained. Regular engagement was held and relationships had significantly improved.

In February 2025 NHS England had moved NSFT from NHS oversight framework segment 4 (mandated national intensive support) to segment 3 (mandated regional support and oversight). This was in recognition of consistent improvement at the trust. In September 2025 NSFT was placed in segment 4 of the new NHS Oversight Framework.

Local Mind services provided some support commissioned by the trust. There was mixed feedback, with frequent staff changes being reported making it difficult to build relationships with teams. They also reported that referrals from teams were inconsistent in quality and showed a disparity across different areas. There were also concerns raised about payments under some contracts not being timely.

Feedback from local Healthwatch organisations generally noted an improving relationship with the trust alongside greater openness and transparency. Improving collaboration and partnership working was also reported but it was noted also that this needed to be further improved moving forwards.

As part of our assessment we held 2 meetings with a local campaign group. These meetings focused around the experiences of current and ex service users and families. The group voiced continued concerns about care at the trust. They also raised concerns about the way individual complaints had been dealt with and a lack of action around the concerns raised in the process. They reported significant delays in investigation processes and that communication with service users and families could be poor. However, the group did report that the trust now regularly engages with them.

The trust was a partner in the East of England provider collaborative alongside 5 other partner trusts. The collaborative commissions specialised mental health services including children and young people inpatients and admission avoidance schemes, adult eating disorder inpatients and admission avoidance and secure mental health services. Over the past 3 years this collaborative had significantly reduced waiting times as well as the number of people in inpatient treatment through providing viable alternatives. The collaborative was also noted to undertake significant co-production with service users and carers being key participants in clinical design and delivery groups as well as the collaborative board.

The trust governors were provided with training to fulfil their roles. The governor group comprised some longstanding members alongside some who had joined much more recently. Governors reported feeling unclear on how they were able to currently hold NED’s to account with some reporting they felt they were actively discouraged from asking questions. They also reported that there was currently no process to seek the views of governors on a regular basis. Governors also didn’t currently feel supported to reach out to and engage with their local communities, although it was hoped this may improve with the locality leadership model. The trust had made changes to the governor constitution aimed at tackling some of these concerns. An external desktop review of council of governor’s governance commissioned by the trust, also noted the range of opportunities offered to governors to work with non-executive and executive directors and hold them to account. The trust also told us they held pre meetings to give governors the opportunity to prepare prior to formal meetings. The proposed move to align governors to the locality model was seen as a positive, but this had not been fully implemented at the time of our inspection.

The trust strategy included addressing health inequalities and this was one of their large scale change programmes for 25/26. The trust had created a new role in the chief patient experience officer and health inequalities sat within this portfolio. It was acknowledged that historically the trust had not had a focus on health inequality but that the trust’s current restructure was bringing in the necessary expertise to support this. Realignment into locality structures aimed to provide services in a consistent way across the trust footprint reducing variation in patient experience. Working in the locality model also promoted better system working to further support this. This continues to be an area that needs focus moving forwards.

The pharmacy team and chief pharmacist worked closely with other partners in the Integrated Care System (ICS) and national pharmacy leads for mental health. For example, collaborating with ICB Medicines Optimisation teams to develop a NSFT prescribing formulary. Whilst currently not operational, a referral process into the Discharge Medicines Service (DMS)was being developed. The DMS is a community pharmacy service that helps patients who need extra support with their medicines after leaving the hospital. This was a recognised as a needed area of development when compared to other trusts.

The team was working with the Local Medical Committee on the trust's discharge strategy, with the aim to improve the quality and consistency of discharge letters sent to GPs. The medicines improvement plan was presented by the chief pharmacist to the Trust's governors' and patient and public forum, to demonstrate progress and reinforce commitment to improving medicines optimisation across the organisation.

The trust had a process to respond to complaints from people using services. The trust had received 457 complaints in the last 12 months. Of these only 37% were completed within the appropriate time frame. However there did appear to be an improving picture over the last 6 months with 38% of total complaints being classed as overdue at the time of our assessment. Our review of complaints noted that whilst complaints were mostly dealt with effectively, there was some inconsistency in the quality of the response. However, complaints were reported on a weekly basis to the Trust wide Safety Group enabling early identification of themes to support sharing, learning and further examination of root causes. The trust informed us that the executive chief patient experience officer and a director of patient experience would deliver improved leadership in this area as well as establishing a complaints advisory group to deliver consistency in complaints management in the future.

The involvement of people who use services and carers in developing and evaluating improvement had been an area of focus at the trust. The Board had created a new voting role in the Chief Patient Experience Officer and there was as a director of patient experience. The trust had established a Service User and Carer Council, the chair of which attended trust board. There were also plans to develop 5 separate councils based within the localities. The council aimed to empower those with lived experience to be involved in discussions aroundquality,experience, andservice monitoringorimprovement.

Involving service users carers and families was also an area of focus within clinical transformation programmes. For example, as part of the inpatient programme there was a Lived Experience Advisory Group (LEAG) co-chaired by two people with lived experience. This group supported the workstream and decision making.

The group supported both previous and current inpatients to attend ensuring knowledge is current. As part of this programme experts by experience were also supported to be involved in the delivery of training for staff.

A service user reference group was established to review and comment on a new standard operating procedure (SOP) for the Crisis Resolution and Home Treatment team (CRHTT). Alongside this a group of service users and carers also engaged with NSFT staff, stakeholders and partners as part of workshops to shape new model for NHS 111 mental health option.   

For the Children and Young People programme, services users, carers and families were involved in the THRIVE (a mental health an emotional wellbeing framework for children, young people and their families) groups, development of care pathways, and workshops on establishing appropriate age ranges. 

A Listening into Action (LiA) programme was implemented in the trust at the end of 2023 and was now well-established. Alongside staff involvement there was also an LiA Think Family and Carer group. LiA is a programme aimed at delivery staff led change. In 2024 27 ‘pioneer’ teams had delivered on focussed 20 week projects. These projects included a project focussed on enhancing the quality of clinical supervision and a programme streamlining the process of recruiting support workers. Over 170 ‘quick wins’ had also been reported so far as part of the programme. Staff engagement with and feedback on the programme was generally positive.

Quality Improvement (QI) had previously not been an area of focus at the trust and the approach had not been fully embedded. However, the trust had invested in QI appointing a senior clinician to take the lead on both LiA and QI. There were currently 36 active QI projects at the trust and 3 collaboratives had been facilitated in 2024/25.These included a falls collaborative focussed on reducing falls and a safewards collaborative aimed at reducing conflict and aggression on inpatient wards. The trust had also significantly increased expert by experience involvement in QI projects with 92% having lived experience involvement. There was work being done at the trust to integrate the LiA programme with QI.

The trust had a research department which was involved in national research programmes. The teams also connected with local universities. Research focussed on 2 areas, national targets and priorities and more expansive projects including some connected to the local population such as a project working with young farmers at risk of suicide. There was currently no research strategy at the trust and research projects were only externally funded. There was scope for further development of research at the trust moving forwards.

During 2024/25 the trust participated in 5 national clinical audits and 4 national confidential enquiries which covered the relevant health services provided by the trust. There was trust wide local audit programme across wards, crisis and home treatment teams, community mental health teams and specialist teams for services provided to all ages. A total of 42 audits were registered during the year, with 24 completed. These covered variety of topics, including physical health monitoring, antipsychotics and discharge planning and letters. Actions from these audits were reported to the quality committee.

The trust had 8 accreditations from the Royal College of Psychiatrists across inpatient and community services. There were 2 further teams awaiting reassessment.

The trust has undertaken significant work around learning from deaths. An independent report into NSFT’s mortality recording and reporting was published in June 2023. Findings raised concerns about inconsistency in both reporting and processing mortality data. A new integrated reporting system had been designed and implemented in November 2023 and an independent clinical team had completed a case by case review of deaths to ensure a robust review of historic records. The trust had commissioned a review of their reporting process that gave a high level of confidence that deaths were being appropriately traced and recorded.

Having embedded the process, the trust had a focus on improving learning over the next year. They had identified points at which learning could and was being shared including the trust wide safety group and locality quality groups. There were also patient safety alerts and 7 minute briefings disseminated to staff. The trust also ran a bi-monthly learning from events group which included carers and external stakeholders. Further work was being done to look at ways to ensure learning was shared with a wider group of staff and ensure consistent changes in clinical practice.

The trust had been an early adopter of the patient safety incident response framework (PSIRF). There was a patient safety incident response plan (PSIRP) in place for 2025/26. There were 7 local priorities: self-harm/suicide, carer engagement, physical health monitoring, medication management, cross-agency working and use of restrictive practices.

We reviewed a number of patient safety incident investigations (PSII) and serious incident reviews (SIR) as part of our assessment. This noted that although initial screening appeared to be done promptly, investigations appeared to be thorough and families were appropriately involved in the process, there were often significant delays of up to a year in SIRs and PSIIs being completed and shared. This impacted the ability to extract and implement learning identified from incidents. Delays in completion of patient safety investigations was also a concern raised by some stakeholders.

At the point of our assessment the average time taken to complete investigations was 4-5 months for an SIR and 10 months for a PSII. However, the trust had recognised this and created a PSIRF work plan. This set a target of 80 working days. for completion with delivery of such timeframes starting from October 2025. The trust had undertaken a review of the safer care directorate and invested in a new senior leadership structure. Steps taken to support delivery to this improved timeframe included remodelling of patient safety governance processes and report templates. The director of safer care was also meeting weekly with the patient safety team to address and delays and any immediate learning was to be flagged at the weekly Trust Safety Group. An additional issue recognised by the trust was that there was an insufficient number of staff currently trained in PSIRF investigation methods. Additional training had been put in place over the coming months to improve capacity.

Mandatory training completion rates were good across all localities with all achieving a compliance rate of 92% or higher although there was some variation across different modules and specific teams. Compliance rates to appraisal and supervision competition were also good although clinical supervision was a notable outlier sitting at only 71%. This was a as particular issue across a number of the localities.

The Trust has a Green Plan, in line with national guidance, which was recently updated in 2025 and published in line with national guidance and the trusts goals. Leaders acknowledged the importance of ensuring Green Plan goals were being delivered upon, and there was clear evidence of oversight of the green plan from the board. There was governance in place to ensure performance against targets, with quarterly meetings of the well led sustainability forum who report upwards to the board on their progress. The Trust also had a board level lead for Net Zero. The trust board was updated on the Green Plan progress within the annual report, for which different departments across the trust fed in their progress. Clear examples were provided of how the board is engaged in the sustainability agenda for example with training being made available from the sustainability manager to outline the trusts goals and achievements. There has been a recent restructure to ensure there is an environmental sustainability group that meets with people from each locality which fed into the performance and finance committee and eventually to the board.

The large geographical area of the trust number of agency staff was identified as a challenge for engagement in the Net Zero goals. The Trust had tried to engage staff by encouraging Green Champions, which they hope will form an information sharing network as well as providing a presentation at staff induction around sustainability. Staff were supported to attend courses externally, within the ICB, but outside of the initial presentation provided at staff induction, there were no internal courses available to trust staff. There was support for staff to become involved in research and quality improvement projects which have a sustainability focus, with examples outlined. There was also a clear understanding of how sustainability initiatives can benefit staff.

There was a clear connection between the sustainability projects within the organisation and the trust’s core purpose delivering mental health services. We heard clear examples of projects that whilst advancing sustainability also connected to and promoted mental health.

The trust is clearly engaged with the ICB around sustainability, with acknowledgement of their contribution to the ICS Green Plan and attendance at regular sustainability meetings. The Trust contributed to the national data return on their emissions and were committed to national initiatives for reducing emissions in the NHS for example within medicines, estates and procurement. The trust had continued to make a 100% commitment to renewable energy and had a successful recycling project for unused medical equipment which is either sent to Ukraine or donated to charity.

Within some areas, such as estates, travel and transport, there was a clear understanding of where reduction in emissions can be achieved, and the trust had been successful in these initiatives. For example, purchasing 100% renewable energy and the move towards more electric vehicles for trust use. However, there were challenges around other areas of focus such as care pathways which leaders stated hadn’t yet been addressed from a sustainability perspective. However, the trust had plans to include sustainability in their approach to making care pathways more efficient and leaders understood how more could be done to encourage staff on the ground to consider sustainability in how care is delivered.