All inspections: Norfolk and Suffolk NHS Foundation Trust

We inspected Norfolk and Suffolk NHS Foundation Trust because at our last inspection we rated the trust inadequate overall and took enforcement action.

We carried out an unannounced comprehensive inspection of 2 core services – child and adolescent mental health wards and community-based mental health services for adults of working age; and unannounced focussed inspections of 4 core services which were - acute wards for adults of working age and psychiatric intensive care units, long stay or rehabilitation mental health wards for working age adults, mental health crisis services and health-based places of safety and wards for older people with mental health problems. We also inspected the well-led key question for the trust overall.

We chose these 6 core services to see if they had complied with the warning notice we issued and if there had been improvements since our last inspection in November and December 2021.

The trust provides the following mental health services, which we did not inspect this time:

• Wards for people with a learning disability or autism.

• Specialist community mental health services for children and young people.

• Community based services for older people

• Forensic inpatient or secure wards

• Community mental health services for people with a learning disability or autism

Our rating of services improved. We rated them as requires improvement because:

We rated safe, effective, responsive and well-led as requires improvement, and caring as good.
Three of the core services we inspected had improved. The child and adolescent mental health ward had improved from a rating of inadequate to a new rating of good. The acute wards for adults of a working age and the community-based mental health services for working age adults had both improved from a rating of inadequate to a new rating of requires improvement. One core service, mental health crisis services had remained requires improvement overall. The other 2 services, rehabilitation ward and wards for older people with mental health problems could not be rated as we only inspected a few of the key questions. Our overall rating took into account the current ratings of the 5 core services we did not inspect at this time.
Across the 6 core services we rated 24 domains associated with the key questions. Four domains had improved by 2 ratings from inadequate to good; 10 had improved by 1 rating; 9 had stayed the same and 1 had seen a reduction in the rating.
The most concerning ratings were the inadequate ratings for the safe domain for acute wards for adults of a working age and wards for older people with mental health problems. For these services we found that improvements required at the last inspection as stated in the warning notice had not been achieved consistently across the wards. For example, on a few wards ligature reduction work had not yet taken place (although was planned); some wards did not have enough staff who had completed the mandatory training; a few staff were not carrying out restrictive interventions appropriately such as restraint or seclusion. There were still a small number of wards where standards of care needed to significantly improve. This demonstrated that the positive changes focusing on patient safety introduced at pace by the trust since the last inspection needed some further refinement and embedding to improve the consistency of care. The trust recognised that there were still challenges, but the Care Quality Commission had confidence that the trust had leaders with the commitment and experience to continue to take this forward at pace as demonstrated by services with improved ratings.
Whilst the rating of the trust had improved the Care Quality Commission chief inspector of hospitals has recommended to NHS England and NHS Improvement that the trust remains in the Recovery Support Programme at the current level to ensure it receives ongoing relevant support to continue to make the changes required.

Our inspection identified the following areas where further improvement was needed:

The trust had access to a wide range of data including staffing, incidents, complaints, safeguarding, whistleblowing, feedback from quality and safety review visits but this was not always brought together effectively. This meant that services which were struggling might not be identified at an early stage to ensure they had the necessary ‘wrap around’ support package to improve in a timely manner.
There are examples of where essential environmental improvements had not happened fast enough to address patient safety concerns and whilst systems were in place to request this work, further input was needed to ensure repairs took place in a timely manner.
We observed a range of ability and confidence in ward and team managers and in middle management in the care groups. Managers were not always escalating concerns quickly enough to get the help they needed. The services where we had the most concerns on this inspection were also where managers appeared to lack experience or motivation. Whilst the trust had leadership development opportunities in place both for groups and individuals, these needed to be further developed to support people to perform to a consistently high standard. The trust had secured funding to increase their leadership development team with plans to develop a talent management programme, but this had not yet come into effect.
Clinical leadership needed to develop and embed further. For nurses there was a well-developed nurse leadership structure reflecting the geography of the trust and the patient safety priorities for the chief nurse. Allied health professionals were line managed by the chief nurse. Each care group was led by a clinical director (mostly medics), a lead nurse, a service director and people participation lead. Despite these leadership roles the consultant psychiatrists did not feel they were fully engaged in decision making relating to the trust and there was an acknowledgement that this could improve. The chief medical officer planned to actively involve the medics in looking at future models of care which was welcomed by the consultant psychiatrists. He was developing plans to improve their leadership development. He was also reviewing the engagement of junior doctors. It was also acknowledged by the trust that the psychologists should either be managed by the chief medical officer or chief nurse rather than the current arrangement of management by the deputy chief executive.
The trust had considerable further work to undertake in terms of their digital transformation. The current contract for the patient record system will expire in April 2025 and they were deciding which system would be best meet their needs going forward. This decision making was been operationally led by the chief operating officer. In the meantime, access to live data was limited to identify areas for improvement and inform managerial decision making. Some data was available through Power BI, but many staff did not have the skills to access and make use of this. However, at a trust wide level for key governance committees, data was felt to be largely accurate, well presented and appropriately analysed.

Our inspection identified a number of areas where improvements had taken place:

The trust was moving from a position of being reactive in response to external stakeholders including the Care Quality Commission to being proactive. There was a clear and realistic plan in place to deliver phased improvement. The inspection found evidence of the work being done to address the basics. There were many examples of this including mandatory training compliance at 90%, appraisal completion rates at 95%, improved systems and training for conducting therapeutic observations of patients and improvements to medicine management. The Care Quality Commission inspection found an example of where a restraint had been carried out in an unacceptable manner, however systemic improvements were taking place which should reduce the likelihood of this happening in the future. This included the rolling out of accredited training for the prevention and management of violence and aggression where most staff had been trained or their training was booked and the strengthening of a trust wide team supporting wards to reduce the use of physical interventions and where needed ensure this is done appropriately.
Since the last inspection the executive leadership team had strengthened. The 3 appointments had come with considerable experience, the deputy chief executive and chief people officer, chief medical officer and chief operating officer. The executive leadership team had clear leadership roles for delivering the strategic priorities and were actively working on translating this into practice. For example, the chief operating officer was leading work to deliver timely access to services. This included ensuring there was an understanding of the reasons for waiting lists, improving the quality of the data, reviewing the models of services and reducing unwarranted variations between similar teams. Our inspections of adult community mental health teams found that whilst there were waiting lists, the people on them were being monitored and receiving access to some therapeutic input. The chief operating officer recognised the complexity of this work and the need to engage with external stakeholders such as NHSE and join programmes to learn from other providers.
Since the last inspection the governance processes had been strengthened. The number of sub-committees of the Board had been reduced to streamline the systems for gaining assurance. External stakeholders had become active participants in the governance processes through membership of committees. We found examples of where assurance processes had been strengthened. The trust had developed an evidence assurance group to ensure the data being used to monitor progress with the Care Quality Commission action plan was accurate and corroborated to ensure the improvements were really happening in practice. The trust had strengthened a team which visited wards and teams to carry out quality and safety reviews. This team had carried out over 100 visits between March to October 2022 and these included patient representatives and external stakeholders. This had identified areas for improvement both for individual service. and trust wide. This had led to changes such as an improved staff induction process. The trust had just introduced a new method of completing clinical audits which were done online with the results submitted electronically. These audits reflected the areas identified at the last inspection where improvements were needed. The chief operating officer had strengthened assurance through the quality performance meetings where the care groups were held to account for the services they managed. These were now taking place monthly, made better use of data and set clearer expectations in terms of improvements. Finally, the number of visits of executives and non-executive directors to services had increased. Twenty-nine visits had taken place since late spring by the chair and non-executive directors to services. Following our inspection there was a recognition that assurance could be strengthened further – particularly the review of incidents through viewing CCTV. This had been taking place, but the quantity and quality of this review was being developed.
There was a full recognition by the trust of the need to improve the culture of the organisation. Many of the staff we met during the inspection talked about the improvements in the culture, but it was clear that there were still some teams where staff were experiencing discrimination and had poor morale. Since the last inspection work had taken place to start improving the culture although there was a recognition that it would take time to see significant changes in measures such as the staff survey results although the trust were hopeful of seeing a few green shoots. The trust leaders recognised the importance of role modelling the appropriate behaviours which was very evident throughout the well led review. They were clear of the need to avoid a blame culture and create one where staff felt supported to learn and improve. They had introduced a leadership and management behaviour framework. Executive leaders were holding weekly online ‘hear to listen’ events where any staff could join and ask any question anonymously if they wished. The calls were recorded for colleagues who could not join at the time and were being attended by 200-300 staff. The trust had launched a trust wide piece of work to listen to staff and turn this into action and about 30% of the trust staff had chosen to complete the initial survey. These results were available at the time of the inspection and were enabling the trust to start understanding the scale and nature of the issues. The process will support further work with teams to listen and promote improvements. The trust was working to improve opportunities for staff to speak up and had just started to use an external speak up guardian arrangement to ensure greater independence from the trust. The trust was supporting the staff networks, which each had an executive sponsor, and had been provided with extra resources to develop further.
The trust had recognised that it needed to bring forward the work to refresh the trust strategy to align with the plans in the wider health and social care economy across the 2 system geographies. The aim was to have a new strategy by April 2023 and use the ongoing staff engagement work to consult as needed. The refreshed strategy would be clinically led and clinically informed by the work which had been started by the chief medical officer to look at future models of care. There were plans to also refresh the workforce, estates and digital supporting strategies later in the year. At the time of the inspection the trust strategy was displayed across the services, was available on the intranet, used to align governance papers but not widely referred to by members of staff.
The trust was actively involved in the work across both care systems in Norfolk and Suffolk. The chief executive was a member of both Integrated Care Boards. The trust leaders understood that there needed to be effective system working to meet the mental health needs of the population. They also recognised that the focus should not be on growing the trust, but rather to identify the areas they could do well as a secondary healthcare provider and where other providers including those in the third sector were better placed to meet people’s needs. Since the last inspection there had been the addition of an Improvement Board as a sub-committee of the Board to support partner engagement and monitor trust progress. There were positive examples of collaborative working. This included mental health nurses working in primary care across both systems. In West Suffolk the trust was working with Mind to support people with long term mental health conditions. Mind were able to offer people up to 3 interventions a week such as help with accessing fitness activities to improve their overall health. The trust recognised that there was scope to significantly grow this collaborative working.
Patient participation had embedded further across the trust over the last year. There were 8 people participation leads aligned to the care groups and 8 people participation co-ordinators. People participation was embedded across the trust with people with lived experiences actively involved in governance committees, quality assurance work, staff recruitment and training, research and quality improvement work. The trust also employed peer support workers across a range of services.

How we carried out the inspection

Before the inspection visit, we reviewed information that we held about each of the core services.

During the inspection visits, we:

Visited 19 wards and 12 teams
Spoke to 139 staff performing a wide range of roles
Spoke to 96 patients and 24 relatives or carers
Looked at 135 individual patient records
Looked at over 100 medication records
Attended 12 meetings including staff handovers, multidisciplinary meetings and patient community meetings
Looked at a number of records involved in the day to day operation of the services.

You can find further information about how we carry out our inspections on our website: www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

What people who use the service say

In the services we inspected, feedback from patients and carers was largely positive. On the child and adolescent mental health ward, patients said they felt safe and well cared for. Patients felt the staff were supportive of their needs and were friendly and approachable, staff had the skills to meet their needs and helped them through crisis and in difficult situations. Patients said the ward was calm and that there were enough staff to meet their needs and go out on activities and leave. On the acute wards for adults of working age and psychiatric intensive care units, patients were mostly happy with the care they received, thought there were enough staff to deliver care, felt safe on the wards and said that staff looked after their physical health. Patients told us they were involved in their care decisions. Overall patients thought that wards were clean and that they could give feedback about their care. On the long stay/rehabilitation mental health ward for working age adults, all patients said they felt safe on the ward and staff were kind, they felt listened to, and staff helped them when they needed it. On the wards for older people with mental health problems, patients told us they felt the staff treated them like human beings, and the atmosphere in the wards was relaxed and safe. Patients told us staff were always around and getting staff attention wasn't a problem. They felt involved in their care planning and decision-making and were able to be supported by their family members in the care planning process. Patients told us they were able to go to their weekly ward round to ask questions about their care.

In the community-based mental health services for adults of working age, most service users and carers we spoke to were very positive about the service. They told us staff were good at communicating with them and had a caring approach. All patient felt listened to, and said they were fully involved in their care. Feedback from carers was positive about the care and treatment family members received. Relatives told us that staff were supportive and they kept them involved in their loved one’s care. In the mental health crisis services and health-based places of safety, most patients and carers we spoke with said they were seen within the timeframe the staff told them when they initially called them, and they were seen regularly, which changed frequency dependant on their level of need. All patients and carers we spoke with told us patients received their medicines on time.

There were however some areas for improvement identified by people who used the service. On the acute wards for adults of working age and psychiatric intensive care units, 2 patients gave us examples where staff had not always been kind and polite and a further 4 said night staff were not always responsive to them, 1 patient had specific concerns about their care which we followed up with ward staff. Several patients told us they did not have a copy of their care plan or had not been given enough information about the medicines they were prescribed or the about ward when they were first admitted. In the mental health crisis services and health-based places of safety, 3 patients said they had no care plan and were not given a copy. Four carers said their relative had no care plan and 5 carers said they had not been given a copy. One patient told us they had no advice regarding their medicines.

We carried out this unannounced inspection of eight of the mental health core services provided by this trust because at our most recent inspection we rated the trust overall as requires improvement and it was in special measures, and we received information giving us concerns about the safety and quality of some of the services. We also inspected the well-led key question for the trust overall.

We inspected five mental health inpatient services and three community mental health services:

acute wards for adults of working age and psychiatric intensive care units long stay or rehabilitation mental health wards for working age adults.
child and adolescent mental health wards.
wards for older people with mental health problems.
wards for people with a learning disability or autism.
community-based mental health services for adults of working age.
mental health crisis services and health based places of safety.
specialist community mental health services for children and young people.

We did not inspect the following core services at this inspection:

community based services for older people
forensic inpatient wards
community mental health services for people with a learning disability
We are monitoring the progress of these services and will re-inspect them as appropriate.

Our rating of services went down. We rated them as inadequate because:

We rated safe overall as inadequate in four out of the eight services inspected in this domain, this was a deterioration from the earlier inspection.

We rated effective overall as inadequate in three of the core services inspected this time in this domain, five services required improvement, three service were good in this domain.

We rated caring overall as good, as two services required improvement in this domain and the remainder were good.

We rated responsive as requires improvement overall, as five of the services required improvement, one was inadequate, and the remainder good.

We rated well led as inadequate overall, as two core services inspected were inadequate in this domain, and six services inspected required improvement, and two as good.

At this inspection we rated three of the trust’s services as inadequate overall in this domain, five as requires improvement and three as good. In rating the trust overall, we took into account the current ratings of the three services we did not inspect this time.

During the inspection of the core services, we served the provider with a letter of intent under Section 31 of the Health and Social Care Act 2008, to warn them of possible urgent enforcement action. We told the provider that we were considering whether to use our powers to urgently impose conditions on their registration. The effect of using Section 31 powers is serious and immediate. The provider was told to submit an action plan that described how it was addressing the urgent concerns. Their response provided enough assurance that they had acted to address immediate concerns and so we did not take forward urgent enforcement action.

However, following the inspection we served the provider with a Section 29A Warning Notice relating to five registered locations; Trust Headquarters, Julian Hospital, St Clements Hospital, Northgate Hospital, Carlton Court. The Commission served a Section 29A Warning Notice because the quality of health care provided required significant improvement in the following areas:

The trust did not consistently maintain safe staffing levels or ensuring there were enough suitably qualified staff to meet the needs of people using services. We found this was impacting on the level of safety staff and patients feel, the governance within teams and multidisciplinary team effectiveness and patent safety.
The trust did not ensure staff had the mandatory training and specialist training to undertake safe care and treatment of patients.
The trust did not ensure staff received supervision and appraisals to support the development of staff in their roles and to support safe and effective care.
The trust did not ensure staff were aware of ligature assessments or mitigated or removed ligature points effectively to maintain patient safety.
The trust did not ensure patients had up to date risk assessments and risk management plans to manage risks and ensure patient safety.
The trust did not manage long waiting lists or monitor the risk within the waiting lists effectively.
The trust did not ensure staff reported, managed and learnt from incidents in order to protect patients and staff from harm.
The trust was not ensuring staff carried out patient observations in accordance with trust policy and NICE guidance in order to protect people from harm.
The trust did not ensure staff had access to patient records or maintained accurate records regarding patient care, physical health checks and nutrition in order to meet or demonstrate patient needs had been met.
The trust did not ensure patients were introduced to the ward area, privacy was respected in both the environment and by knocking on doors or through patient involvement in their care.
The trust did not ensure patient outcomes were measured to demonstrate progress being made.
The trust did not ensure effective medicine management was taking place effectively to maintain patient safety.
The trust did not ensure that cultures were supportive of staff to work in to provide care.
The trust did not provide support to teams to maintain good governance in providing high quality care.

The Warning Notice set out a legally-set timescale for the provider to become compliant. A further inspection will be carried out to ensure action has been taken to comply with the Warning Notice.

Overall Summary

The trust did not consistently maintain safe staffing levels or ensure there were enough suitably qualified staff to meet the needs of people using services. We found this was impacting on the level of safety for staff and patients. It also impacted on governance within teams, multidisciplinary team effectiveness and patient safety. The trust did not provide support to teams to maintain good governance in providing high quality care.
The trust did not ensure effective management of medicines was taking place effectively to maintain patient safety.
The trust did not ensure staff were aware of ligature risks assessments and did not mitigate or remove ligature points in a timely manner to maintain patient safety.
The trust did not ensure all patients had up-to-date risk assessments or plans to manage risks to ensure patient safety.
The trust did not manage long waiting lists or monitor the risk within the waiting lists effectively to ensure patients did not deteriorate whilst awaiting treatment.
The trust did not ensure staff carried out patient observations in accordance with trust policy and National Institute of Health Care and Excellence guidance to protect patients from harm.
The trust did not ensure patient outcomes measures were used to demonstrate progress made.
The trust did not ensure staff had access to patient records or maintained accurate records regarding patient care, physical health checks and nutrition to meet or demonstrate meeting patient needs.
The trust did not ensure staff undertook the mandatory training required to deliver safe care and treatment of patients.
The trust did not ensure staff received training, supervision, and appraisals to support the development of their roles to support safe and effective care.
The trust did not ensure staff reported, managed, and learnt from patient incidents to protect patients from harm.
The trust did not ensure that cultures were supportive of staff to work in to provide care in some service areas.
The trust needed to strengthen relationships with stakeholders to improve patient pathways, especially in relation to children and young people.
The trust did not demonstrate information provided to the board and media was open and transparent relating to CQC initial feedback and ward closures.

However:

The trust maintained its services throughout the pandemic, and staff teams supported each other during this crisis.
The trust had made progress in implementing a model of patient participation in all aspects of its work.
The trust had made progress in developing clinical leadership and in investing in leadership development.
The trust was making good progress in developing an overall engaging culture which staff reported as going in the right direction.
The trust improved relationships and worked well with trade unions and governors resulting in joint working.
The trust participated in the integrated care systems as an equal partner and led on mental health. Stakeholders and staff described “green shoots” developing in the trust, implying it was going in the right direction.
The trust participated in a range of research projects and quality improvement initiatives involving staff, patients, carers and the community. Training, research and quality improvement worked well together around quality improvement.
The trust had implemented a successful restraint reduction programme, by taking a human rights approach there had been significant reductions.
The trust will continue to work with the NHS England and Improvement Intensive Support for Challenged Systems team (a team that works with challenged providers).

How we carried out the inspection

Before the inspection visit, we reviewed information that we held about each of the core services. During the inspection visits, we:

visited the wards and observed how staff cared for patients.
toured the clinical environments on the wards and in community locations.
visited four health based places of safety suites.
spoke with 301 operational staff including matrons, nurses, clinical support workers assistant practitioners, occupational therapists, psychologists, doctors, social workers physiotherapists, activities coordinators and technical instructors.
spoke with 15 ward managers.
spoke with three students.
spoke with 75 patients.
spoke with 41 carers.
spoke with 3 advocates.
looked at 144 medicines prescription charts.
looked at 212 care records.
looked at 37 observation records.
looked at 35 risk assessments.
looked at 37 observation records.
looked at 17 leave risk assessments.
observed two virtual clinical appointments and a therapy session.
looked at closed circuit television on the acute admission wards and child and adolescent mental health inpatient ward.
also observed a range of meetings including staff handovers, care programme approach meetings, multidisciplinary team meetings, team huddles, patient community meetings, reflective practice, duty meeting and referral meeting, after care meeting, red and green risk meeting, safety huddle and bed management meeting, and a meeting with a voluntary mental health organisation.

The well led inspection was carried out virtually due to the increased concerns about the COVID-19 pandemic at the time. The inspection team:

interviewed the executive directors and non-executive directors.
undertook focus groups with governors, non-executive directors, modern matrons, service directors, clinical directors, consultants, junior doctors, equality, and diversity leads, and research training and quality improvement leads.
observed a private and public trust board meeting, a finance committee meeting, patient participant meeting, governors meeting and Mental Health Act meeting.
spoke and received information from a range of statutory stakeholders such as the National Health Service England/Improvement (NHSE/I) lead, Clinical Commissioning Groups (CCGs), public health director, acute hospitals, Nursing and Midwifery Council, Integrated Care Systems (ICS) leads, Health Education England.
spoke with and received information from voluntary stakeholders and campaign groups.
interviewed a range of senior managers including heads of information management and technology, quality, estates, finance, pharmacy, guardian of safe working hours, speak up guardian, staff side officer, complaints, risk, clinical safety officer, fire safety officer, patient safety officer, trade union, Mental Health Act administrator, advocacy and Mental Health Act leads.
looked at a range of board papers, documents, and strategies.

You can find further information about how we carry out our inspections on our website: www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

What people who use the service say

Across the core services inspected there was a mixed response by patients and carers.

Patients and carers provided positive feedback about staff, their involvement in care on the wards for older people, long stay rehabilitation and for people with learning disability and autism. Patients told us staff treated patients with compassion and kindness. They respected patients’ privacy and dignity. They understood the individual needs of patients and supported patients to understand and manage their care, treatment, or condition. Patients could keep in contact with their family and friends. They had access to advocates and care coordinators from the community mental health teams. They knew how to give feedback on their care including how to make a complaint.

In the community child and adolescent mental health service, people told us staff were always polite and interested in the young persons’ wellbeing and always asked how the parent or carer was doing.

In the crisis team we spoke with 25 patients and six carers. Feedback was positive. They said staff were respectful, compassionate, polite, and caring. Patients were involved in their care and decisions made about them. Carer involvement occurred with patient consent. Staff considered carers needs and signposted them to local services where required. Staff were efficient and responded quickly to concerns.

In the adult community team nine patients were happy with their care and treatment. Two patients said they had had the same coordinator for a long time and had experienced no problems. Two patients described staff as being kind. One patient told us “Everybody’s friendly, nice and really good”, adding that their care coordinator “came to work to see me one day when I was struggling and took me to get a cup of coffee”. One patient stated staff were “always positive, understanding, caring, will listen to you moan, will give you another idea if something isn’t working, always on your side, give you a reality check that what your feeling is normal. They’re brilliant.”

Within the community child and adolescent service young people and carers told us that it was a frustrating and lengthy process accessing the service. Two out of the 23 people we spoke with had not been involved in their care planning. Out of the 16 carers we spoke to, 12 said they had not received a carers assessment offer.

Young people in the child and adolescent services told us not all staff were kind to them or understood their mental health issues. They said some staff spoke to them in a negative way. For example, saying they “were wasting their opportunities to get better and behaving in an immature way or behaving in ways to get attention”.

Three young people told us some staff did not seem to know what they were doing or how to care for them. These patients said that they felt staff were afraid to challenge them and did not enforce ward rules or structures. Young people told us this meant some staff did not seem concerned about what they did as long as they did not hurt themselves or cause damage.

Within the adult acute admission services, two patients on Glaven ward reported they would often retreat to their bedroom to protect themselves during incidents occurring on the ward. A patient on Southgate ward told us that staff made inappropriate jokes about him and one relative from Glaven ward told us staff could be rude over the telephone.

On Southgate, Northgate and Glaven wards, patients did not feel carers were always involved in their care and treatment. Carers who we spoke to also confirmed they did not always feel informed about their relative’s care and treatment and or receive any information when their relative was admitted to the ward.

Patients from all adult acute admission wards did not feel involved regarding decisions relating to the running of the service and did not feel they had opportunities to supply feedback on the wards. Two patients on Southgate ward, four patients on Northgate ward and one patient on Glaven ward did not feel involved within their own care. Three patients on Glaven ward told us they had not received an information pack on admission or shown around when they arrived at the ward.

Patients from three wards told us they felt the wards were short staffed, two on Southgate, five on Northgate. On Glaven ward, one patient told us that the lack of staff impacted on their ability to make a hot drink during the daytime, as the coffee was locked away, and staff had to get this for them. A carer for a patient on Glaven ward told us they were concerned about the number of illegal substances on the ward, and staff were not always taking appropriate action when they were informed about this.

In the crisis team some patients said they would have liked to see the same staff member on a regular basis to prevent repetition and for continuity of care. One patient said there was a long wait to see a psychologist. Patients reported limited activities across all wards and said there was not a lot to do and internet access across all wards was poor.

In the adult community mental health team, five patients raised concerns about the standard of care they had received. Individual patients told us:

Their care coordinator “neither cared nor coordinated”, adding they had asked to change care coordinator.
Their care coordinator had not responded to a request made over two weeks ago.
Staff “didn’t have my wellbeing at heart”.

Out of seven carers, two carers expressed concerns about the service. Feedback included:

The care-coordinator situation as a “nightmare due to swaps between teams and sickness” and told us “the impact was that the patient has had no support since July and was now unwell”.
Their relative had had lots of consultants, one who was particularly good who had left, which meant it had now been difficult to get an appointment with a consultant.

We carried out this unannounced, focused inspection of Southgate Ward because we received information giving us concerns about the safety and quality of the services.

Norfolk and Suffolk NHS Foundation Trust provides services for adults and children with mental health needs across Norfolk and Suffolk. Services to people with a learning disability are provided in Suffolk. Southgate Ward is a mixed sex acute admissions ward, with 16 beds, for acutely unwell adult patients. This ward is based at Wedgwood House in Bury St Edmunds, Suffolk. The ward is included in the Trust’s portfolio of acute wards for adults of working age and psychiatric intensive care units.

We did not inspect the other acute wards within the trust because we were responding to concerns raised specifically about Southgate ward. We are monitoring the progress of improvements to services and will re-inspect them as appropriate.

We did not rate this service at this inspection. The previous rating of requires improvement remains.

We found:

Staffing was challenging for this service. On the day of the inspection, we were shown rotas that indicated there were a number of occasions where the staffing levels on the ward fell below the safer staffing levels set by the Trust. Following the inspection, the Trust told us that, on these occasions, managers moved staff from other wards or deployed the unit duty senior nurse onto the ward. All the staff we spoke with told us it was a challenge to provide quality care, spend one to one time with patients and keep patient care plans updated.
The service did not always have enough staff on each shift to carry out any physical interventions safely. Staff had not completed and were not up to date with mandatory ‘Prevention and Management of Aggression (PMA) – Physical Intervention training’. At the time of the inspection, the ward manager provided evidence that only 11% of staff were up to date with physical intervention training and 63% of staff were up to date with personal safety training. Following the inspection, the Trust told us that due to an error in their recording system, the actual compliance rate for PMA training was 34%
Managers did not always support staff through regular, constructive clinical supervision of their work. At the time of the inspection, the supervision compliance figure for Southgate was 47%. At this time there was increased acuity on the wards and staff would have particularly needed support to prevent burnout and a culture where poor practice could develop. The Trust told us they provided others systems of support for staff such as multi-disciplinary team discussions, reflective practice sessions and awaydays.
Staff did not always follow trust policies and procedures when they needed to search patients, or their bedrooms, to keep them safe from harm.

However:

Managers deployed staff to ensure that general and enhanced observations were prioritised to keep patients safe. Managers checked that staff were carrying out observations as per the therapeutic observation policy and patient care plans.
Patients we spoke with told us that, despite being very busy, staff were polite, kind and caring.
The local leaders we spoke with demonstrated the Trusts’ core values.

How we carried out the inspection

During the inspection we:

Spoke with the ward manager for Southgate Ward and the modern matron.
spoke with five staff
spoke with three patients
looked at six care and treatment records
reviewed staffing rotas
reviewed observation records
and reviewed a range of policies and procedures, data and documentation relating to the running of the service.

You can find further information about how we carry out our inspections on our website: www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

What people who use the service say

We spoke with three patients. Patients we spoke with told us that staff were polite and kind and caring, but they were often very busy. All the patients we spoke with told us that there was a lack of activities to do on the ward.

One patient told us that they always felt safe on the ward. One patient told us that sometimes they felt unsafe when other patients were exhibiting distressed behaviours.

One patient we spoke with told us that they were given extra support to enable them to attend a medical examination

Norfolk and Suffolk NHS Foundation Trust provides services for adults and children with mental health needs across Norfolk and Suffolk. Services to people with a learning disability are provided in Suffolk. They also provide secure mental health services across the East of England and work with the criminal justice system. A number of specialist services are also delivered including a community-based eating disorder service.

Samphire ward is a mixed sex ward, with 16 beds for acutely unwell adult patients. This ward opened in July 2019 and is based at Chatterton House in King’s Lynn, Norfolk. The ward is included in the Trust’s portfolio of acute wards for adults of working age and psychiatric intensive care units. This core service was last inspected fully in November 2019 and rated as requires improvement overall. Ratings for safe, responsive, effective and well led were requires improvement and the core service achieved a good rating for caring.

We carried out this unannounced focused inspection of Samphire Ward because we received information giving us concerns about the safety and quality of the service. We visited the ward on 10 May 2021 and carried out remote interviews of staff on 13 May 2021. We focused on specific key lines of enquiry within the safe, caring and well-led domains.

During the inspection we:

Spoke with the Clinical Director and the Service Manager
spoke with seven staff
spoke with eight patients
spoke with an independent advocate
spoke with the Freedom to Speak Up Guardian for the Trust
looked at four care and treatment records
reviewed closed circuit television footage of 26 observations over six time periods.
observed the service ‘safety huddle’
and reviewed a range of policies and procedures, data and documentation relating to the running of the service.

We did not rate this service at this inspection. The previous rating of requires improvement remains. We found:

The service provided safe care. The ward environments were safe and clean. Staff minimised the use of restrictive practices and followed good practice with respect to safeguarding.
We observed that staff completed 24 out of 26 observations correctly and documented these accordingly. We saw staff interacting with patients whilst completing observations.
Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. Care plans were written using respectful language and included the patient voice, i.e. their views and wishes about their treatment and recovery goals.
During the inspection, we observed staff treating patients with care and compassion, respecting their privacy and dignity.
Staff reported receiving regular supervision and valued this opportunity for case reflection and ongoing professional development and we saw that records supported this feedback.
The service was well led, and the governance processes ensured that ward procedures ran smoothly.
The local leaders we spoke with demonstrated the Trusts’ core values. Staff felt able to raise concerns without fear of victimisation.

However:

One member of staff had signed an observation sheet to say they had completed observations on two occasions; however, when we viewed CCTV, we saw that this was not the case. Observations are undertaken when a decision is made that there is an increase of risk of harm. Therefore, the impact could be of significant harm if staff fail to carry out the observations as prescribed. We escalated the concern to the Trust who took swift action.
Feedback from patients was mixed with some patients saying that they felt dismissed, not listened to or not believed. However, staff provided opportunities for patients to share their experiences and facilitated access to advocacy.

How we carried out the inspection

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

What people who use the service say

We spoke with eight patients. Patients we spoke with had mixed views about their care. Six patients told us that staff attitudes varied and while some were very good, some could be uncaring and insensitive in the way they spoke to patients. However, two patients told us that all the staff were kind and caring

Four out of seven patients told us they felt safe on the ward and that staff responded well to patients who became distressed or who presented behaviours that challenged. Two patients told us they sometimes felt safe on the ward and one patient told us they didn’t always feel safe as they would have preferred female staff to do their observations.

The mental health crisis services and health-based places of safety are part of the mental health services delivered by Norfolk and Suffolk NHS Foundation Trust.

The crisis resolution and home treatment teams provide emergency assessments and an alternative to admission to hospital by providing intensive community support for adults who are experiencing acute mental illness with associated risks. The teams were also responsible for admitting patients to an inpatient unit if required. This service is available 24 hours a day, 365 days a year and covers Norfolk and Suffolk.

The health-based place of safety is a place where someone who may be suffering from a mental health problem can be taken by police officers, using the Mental Health Act, to be assessed by a team of mental health professionals.

We conducted an unannounced focussed inspection to respond to concerns that some patients had difficulty accessing crisis services in an emergency. We understood that the trust had set up a new first response service which had been developed to improve access to appropriate services. We also reviewed progress within the service following concerns found at our previous inspection in October 2019.The inspection was undertaken in the days immediately prior to the second national lockdown when the trust were seeing unprecedented demand on services.

We visited four service locations and spoke to staff from crisis, home treatment, psychiatric liaison teams and the new first response service, as well as reviewing the health-based places of safety at each of these locations. We reviewed 36 care records, 50 prescription charts and a range of documentation including policies, standard operating procedures and meeting minutes. We also conducted staff interviews and focus groups remotely following the site visits. We received feedback from several stakeholders regarding patient experience of services.

Our rating of this service stayed the same. We rated it requires improvement because the service did not follow systems and processes to safely prescribe, administer, record and store medicines and governance systems were not effective, the service did not have adequate access to medical cover in Bury St Edmonds and learning was not yet consistently shared with all staff.

The acute wards and psychiatric intensive care units are part of the mental health services delivered by Norfolk and Suffolk NHS Foundation Trust.

These wards provide assessment and treatment in an inpatient care setting for adults either admitted on an informal basis and/or patient detained under the Mental Health Act 1983.

We conducted an unannounced focused inspection of acute wards for adults of working age and psychiatric intensive care units due to concerns about the management of patients with physical health conditions and to check on safety progress within the service following concerns found at our previous inspection in October 2019. The Trust was placed into special measures for the second time in 2017 and has remained in special measures. Trusts in special measures are subject to enhanced monitoring. There had been six deaths of patients using the service since November 2019. Four of these deaths were due to physical health causes including sudden deterioration of their condition. We had received information raising concerns about the safety and quality of the services. The inspection was undertaken in the days immediately prior to the second national lockdown when the Trust were seeing unprecedented demand on services.

During this inspection we visited six wards and inspected specific key lines of enquiry.

We spoke to staff, patients and other stakeholders. We observed care on the wards and reviewed documentation including patients’ care records.

The 15 patients we spoke with had mixed views on the service.

They were mostly happy with the care they received, most felt safe on the wards and felt that staff looked after their physical health. They said staff were kind and respectful, that wards were clean, and that they thought staff had managed risks associated with the COVID-19 pandemic well. Patients could give feedback about their care. Staff communicated well with carers and involved them in patients’ care. However, eight patients said there was not always enough staff, which meant leave, activities and patient meetings or one to one time were sometimes cancelled or postponed. Patients also said they did not always receive a debrief after restraints and six said staff did not always complete enhanced observations properly.

Our rating of this service remained the same. We rated it as requires improvement because:

The service did not always provide safe care as staff did not always assess and manage risk to patients well. There had been incidents of self harm occurring using an item that had been banned from the wards. Not all nurses had completed mandatory basic physical health training. The trust recognised the importance of this and had begun to develop a plan to improve access to training. We also saw staffing that fell below required levels, however we understood that the impact of the pandemic affected the trusts ability to achieve this.
Governance processes did not always ensure that ward procedures ran smoothly and safely, although there had been some improvements made. A bed was not always available locally to a person who would benefit from admission.

However:

The ward environments were safe and clean. Staff followed good practice with respect to safeguarding. Staff recognised incidents and reported them. Medicines were prescribed and administered in line with national guidance.
There were opportunities for staff, carers and patients to give feedback on the service. Leaders had a good understanding of the services they managed. Staff were valued and could raise concerns openly.

We found areas for improvement including three breaches of legal requirements that the trust must put right. We found three things that the trust should improve because it was not doing something required by a regulation, but it would be disproportionate to find a breach of the regulation overall, to prevent it failing to comply with legal requirements in future, or to improve services.

For more information see the areas for improvement section of this report.

This was a focused inspection looking at specific areas of concern. The inspection was of two acute wards, Southgate and Northgate, located at the Wedgwood Unit, West Suffolk Hospital, Bury St Edmunds. The ratings shown in the report are from the previous inspection of acute wards across the trust which took place in October 2019.

We found the following areas the trust needed to improve at Southgate and Northgate wards:

There were a number of occasions where the staffing levels on the wards were below the safer staffing levels set by the trust. Vacancies for registered nurses were 51% and 26% for support workers although recruitment was taking place with some staff due to come into post. Staff and patients described the impact of this. Leave and activities were sometimes cancelled and both patients and staff did not always feel safe on the wards.
Care records had not been fully updated to reflect all the patients’ risks following concerning incidents. There were not always records of a risk assessment being undertaken prior to a patient leaving the ward.
Learning from incidents was not always shared and embedded systematically across the wards. However, staff knew what safety incidents to report and had reported incidents appropriately.
Some mandatory training still needed to take place. Whilst overall compliance across the two wards was 80% some courses had lower completion rates such a fire safety, intermediate life support and adult safeguarding level 3.
Staff were not all receiving regular supervision with their manager, although the trust was working to make improvements and learn from other parts of the organisation where this was going better.
Prior to our inspection there had been gaps and changes to leadership at the hospital. Some staff told us that while senior staff had visited the wards, they did not feel they were being listened to. However, the trust had recently appointed a lead nurse, a temporary modern matron, a permanent ward manager for Northgate ward and a temporary manager for Southgate ward. Staff were positive about the recent appointments. Ward managers told us they felt they had support from senior leaders and that senior leaders had acknowledged staff’s concerns and spent significant time at the wards since January 2020.
Some governance systems needed to be strengthened. For example, it was difficult to get accurate data on staffing levels during the inspection which was essential information needed to manage and monitor the service. However, the trust had recognised prior to the inspection that improvements were needed at the Wedgwood Unit establishing a rapid improvement board and improvement plan.

This was a focused inspection looking at specific areas of concern. The inspection was of the CAMHS youth service located at St Stephens Road, Norwich. The ratings shown in the report are from the previous inspection of specialist community mental health services for children and young people across the trust which took place in October 2019.

At this inspection we found the following areas where the trust needed to improve:

We were not assured that patients who were on waiting lists for assessment or treatment were being adequately managed by the teams responsible for their care. Patients on those waiting lists were not always being adequately monitored or supported. Where a change in the patients’ individual risk was identified, their risk assessments were not always being updated. We also found some appointments and therapy groups being cancelled as there were not enough staff available. This meant that there was a risk that patients whose needs changed might not be identified or receive support in a timely manner.
Whilst the trust was working to rationalise the waiting lists in place and establish a principal list for each team, at the time of the inspection staff were still referring to numerous waiting lists. This was confusing, ineffective and did not ensure there was appropriate oversight for the teams.

The building at 80 St Stephens Road was not well maintained and the décor was shabby. Internet access at the time of the inspection was not reliable which meant that patient records were not always accessible.
Whilst the trust was refining its governance arrangements they were not yet working effectively for this service. The data on waiting lists needed improvement to ensure staff in the teams had the information they needed to meet the needs of the patients. The trust also needed to be assured that patients were being assessed and treated in a timely and safe manner. In addition, the meetings taking place in the service had been revised and needed to be embedded so they were working well. Staff particularly in the North team needed the support and guidance from leaders to use the new systems and processes.

However:

In response to the concerns raised within this report, the trust leadership team provided assurance of action which had begun just prior to the inspection. For instance, on 13 February 2020, an executive-led rapid improvement board had been established. This aimed to accelerate improvements and had increased senior leadership oversight. The care group leadership team were spending four to five days per week at St Stephens Road. We were told of plans in place to undertake a large scale clinical review of the waiting list in early March 2020. A review of the duty system and supervision processes were also planned. New terms of reference for leadership meetings had been agreed including a specific section on learning from incidents, complaints and inquests. A programme of site meetings was planned along with maintenance walkarounds. This had already seen the implementation of hygiene audits and projects identified to improve the environment at 80 St Stephens Road.
Recruitment into posts had begun and we saw key roles had been appointed to with plans in place for further recruitment. The trust had also increased senior management oversight to the service. This was an improvement on staffing which was of particular concern in the North team in December 2019.
Work had begun just prior to this inspection to pull all the waiting lists together and provide a clear view and understanding of action required. This was being developed as one service user tracker list (SUTL) to monitor all patients. This system had been successfully implemented in other teams at the trust. It involved a weekly meeting to discuss actions required for patients on the list.