• Organisation
  • SERVICE PROVIDER

Norfolk and Suffolk NHS Foundation Trust

This is an organisation that runs the health and social care services we inspect

Overall: Requires improvement read more about inspection ratings
Important: Services have been transferred to this provider from another provider

All Inspections

13, 14, 15, 20, 21, 22 September 2022, 1, 2, 15 ,16, 17, 21, 23, 24 November 2022

During a routine inspection

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.

2 November 2021 - 29 December 2021

During a routine inspection

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.

02 September 2021

During an inspection of Acute wards for adults of working age and psychiatric intensive care units

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

10 May on site and 13 May remote interviews

During an inspection of Acute wards for adults of working age and psychiatric intensive care units

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.

3-17 November 2020

During an inspection of Mental health crisis services and health-based places of safety

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.

3 - 11 November 2020

During an inspection of Acute wards for adults of working age and psychiatric intensive care units

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.

24 - 25 February 2020

During an inspection of Acute wards for adults of working age and psychiatric intensive care units

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.

24 - 25 February 2020

During an inspection of Specialist community mental health services for children and young people

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.

07 Oct to 06 Nov 2019

During an inspection of Specialist community mental health services for children and young people

The summary for this service appears in the Overall Summary of this report. 

07 Oct to 06 Nov 2019

During an inspection of Acute wards for adults of working age and psychiatric intensive care units

Our rating of this service improved. We rated it as requires improvement because:

The summary for this service appears in the Overall Summary of this report.

07 Oct to 06 Nov 2019

During an inspection of Wards for older people with mental health problems

Our rating of this service stayed the same. We rated it as good because:

The summary for this service appears in the Overall Summary of this report. 

07 Oct to 06 Nov 2019

During an inspection of Community-based mental health services for older people

Our rating of this service improved. We rated it as good because:

The summary for this service appears in the Overall Summary of this report.

07 Oct to 06 Nov 2019

During an inspection of Mental health crisis services and health-based places of safety

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

The summary for this service appears in the Overall Summary of this report. 

07 Oct to 06 Nov 2019

During a routine inspection

  • We rated well-led, responsive, effective and safe as requires improvement and caring as good. In rating the trust, we took into account the previous ratings of the three core services not inspected this time. We rated the trust overall for well-led as requires improvement. This was an improvement from the last inspection. Four of the trust’s 11 core services are now rated as good and five as requires improvement, one service was outstanding and one inadequate.
  • The trust board and senior leadership team were newly formed. At our inspection in 2018 we had significant concerns about the safety, culture and leadership of the trust. Since then, there had been a change in leadership. At this inspection, we found that, although some of the concerns had not fully been addressed, there had been a shift in approach and foundations had been laid to improve the direction of travel. We saw early improvements in almost all areas, but there had not been enough time to judge if these changes would be sustained. For instance, recent changes to the leadership structure had not yet embedded throughout the whole organisation and there were still a few key posts to be filled. We saw early improvement with the trust moving in the right direction, however, there was still much work to be done.
  • Our findings from key questions demonstrated that whilst governance processes had improved, they had not yet fully ensured that performance and risk were managed well. For instance, waiting lists remained high in the specialist children and young people community mental health teams. Staffing was also a concern within this core service. We saw risk assessments were not always updated within this core service.
  • The environment in the learning disability inpatient service was not safe or fit for purpose. The trust had made little attempt to remove or reduce the number of ligature points or improve lines of sight, nor was it a recovery focussed environment, as it did not encourage independence due to the number of risks within the environment. We had identified in the last inspection that not all wards were safe and fit for purpose.
  • Managers did not have effective oversight of medicines management nor checking of emergency equipment in six of the eight core services we inspected. Despite increased assurance work and an improved board assurance framework, medicines management issues we found had not been identified as a concern by the trust.
  • The trust missed opportunities to prevent or minimise harm. For instance, we found that the management of patients on enhanced observations was not always robust within the inpatient wards with gaps being found in some documents. This posed a direct risk to patient safety. Staff did not ensure patient records in all section 136 suites were completed or added to the system in a timely manner. This posed a risk to patient safety as if the patient accessed another service within the trust there would be no information or previous plan for staff to access and use when making clinical decisions. Staff did not consistently implement the smoke free policy. This led to patient frustration and increased the risk of fire setting.
  • We continued to see similar themes and recommendations (such as poor documentation in clinical records) from serious incident reviews which demonstrated learning was not always effective in improving practice. The trust recognised this and were proactively exploring ways to ensure learning took place across teams.
  • Some services had not yet embraced the cultural changes leaders were trying to develop. In one location in Suffolk, across four core services, we were concerned that some staff continued to report a lack of engagement with managers and pockets of low morale. We also saw evidence of bullying in one team in Norwich. The trust had sight of these issues and had acted, however action taken had not yet been sufficiently embedded to create wholesale change.
  • Some stakeholders did not feel that changes had truly positively impacted all patients, with feedback advising that some still did not feel listened to, with poor communication being a key feature of feedback from patients or their families. Equally, a lack of access to attention deficit hyperactivity disorder (ADHD) services and specialist children and adolescent community services (CAMH) was raised as a concern by stakeholders. We found that this aligned with our findings at this inspection.
  • The new governance and management structure were not yet fully implemented and embedded within the new care groups.  For example, the role of the people participation lead was new and not yet fully developed. Not all staff fully understood the roles and responsibilities of the leads. Leaders had not yet successfully provided all teams across the organisation with an understanding of how the new care groups worked. Some staff expressed concern that the organisational changes were too fast and lacked consultation.
  • Not all teams provided a range of treatment and care for patients based on national guidance and best practice. For instance, some community services had significant waiting times for psychological therapies. Teams lacked enough psychology staff to provide the range of care recommended by the National institute for Health and Care Excellence guidelines.

However:

  • Since the last inspection the trust had implemented a new quality strategy to include quality improvement (QI) as a core component within their strategic direction. The trust quality improvement plan (QIP) had been revised and was aligned to the new strategy. One hundred and eighty-seven staff had completed the three-day improvement leaders programme and were developing initiatives within local teams designed to improve care. Some of these initiatives had been identified as important by the local service users reflecting leaders increased focus on service user participation and co-production. We saw some of these initiatives within the local teams and noted increased efforts made to engage and listen to the service users voice. Staff across services told us that they were involved in the planning and delivery of their own service. This initiative was in the very early stages of implementation and had, therefore, not yet brought about the improvements that were envisaged.
  • The trust had a ‘putting people first’ strategy aimed at improving service user participation and to facilitate cultural change and de-centralise decisions. Concerns had been raised about organisational culture in the last four inspection reports, and the 2018 inspection report identified concerns that there was widespread low morale with staff feeling ‘done to’.  Following the 2018 inspection, the trust leadership team undertook (and continued to undertake) a range of engagement visits to services ensuring they were accessible to staff, although some staff reported that were unaware of visits to their services. At this inspection, more staff reported a sense of optimism and hope that real change was happening. More staff felt listened to, felt they could influence change, felt supported and had good working relationships with their managers.
  • The trust had improved its approach to learning from and managing serious incidents as a result of feedback from families and staff. Trust committees and the trust board had sight of incident data. The trust took proactive steps to address themes identified and improve ways to share learning across services. A new serious incident scrutiny panel and serious incident team had been created to report findings from investigations to the board. The trust recognised there was still work to be done to embed and improve this process further.
  • The trust collected reliable data and analysed it. This was a significant improvement from the last inspection. Staff across most services could find the data they needed, in easily accessible formats, to understand performance, make decisions and improvements. The information systems were integrated and secure. Staff submitted data or notifications to external organisations as required. New ways of monitoring and addressing waiting lists had been implemented with evidence that many lists had reduced. This meant leaders were able to understand what was happening in their organisation and act when needed.
  • The trust had participated in some national improvement and innovation projects and undertook a wide range of quality audits and research. The trust was involved in 65 approved research projects during 2018-19 with 1800 people recruited over the year. The trust was recognised as being in the top 15 highest mental health organisations nationally for research recruitment. The trust had undertaken a quality improvement programme, steered by the Royal College of Psychiatrists, to reduce the incidents of restrictive interventions and restraints as part of a national programme. This was a significant piece of work which continued to have impact. The programme involved the patient voice who shared their experiences with staff. This success has been recognised by the Royal College of Psychiatrists who are leading the national programme.

30 April, 1 and 2 May 2019

During an inspection of Community-based mental health services for adults of working age

We did not revise the rating for this inspection.

This was a focussed, unannounced inspection. We found that some progress had been made in all areas, but not enough to be assured that the requirements had been addressed. Therefore, all requirement notices issued in the last inspection remain in place.

We found the following areas that the Trust needed to improve:

  • The quality of clinical record documentation was variable in some of the services we visited. Staff did not always update risk assessments following a change in risk, and we found out of date risk assessments. Staff had not ensured that crisis plans were in place for all patients.
  • The quality of letters to GP’s varied between teams and not all patients received a copy. These letters also act as a care plan for some patients which meant some patients did not receive a plan of their care.
  • Staff did not always upload clinical information in a timely manner, and information was not stored on the electronic system in a logical or consistent manner. This made it difficult for clinicians to see all interventions and actions in chronological order.
  • We found staff had not always contacted patients as per Trust procedure. The staff at two of the six services we visited could not provide the numbers of patients waiting from referral to assessment and assessment to treatment. This meant we could not be assured that patient risk was always known or managed.
  • The figures held by the local teams for the number of people awaiting assessment and for waiting times differed from, and were generally higher than, the figures held by the Trust. Therefore, we were not assured that managers had oversight of waiting times and that information provided to CQC were accurate.
  • Some adult community teams still had a high number of vacant posts. This impacted on patient waiting times and staff morale in these areas.

However:

  • Staff told us that they felt positive about recent changes to leadership posts and that they were starting to see a positive change in leadership style. Staff felt the Trust board were more visible than the previous board. Staff concerns had been listened to and communication had improved in some areas. Staff were positive about their immediate managers and felt more supported.
  • Clinical documentation was inconsistent across the services we visited. However, in two individual teams, the standard of risk assessment and care plans had improved and included evidence of the patient voice. We also observed some proactive management of risk with clients on waiting lists at Norfolk.
  • Managers used innovative ways of staffing the team in one of the services we visited. This meant roles were identified and posts filled to manage patients risk more effectively.
  • Managers had identified key areas of priority, such as access to services, staff morale, culture and recruitment. Plans were emerging, and some action had begun to take place. There was a sense of urgency to get things right but also recognition of the huge effort and commitment still required to improve the services for adults in the community.

30 April, 1 and 2 May 2019

During an inspection of Mental health crisis services and health-based places of safety

We did not revise the rating for this inspection.

This was a focussed unannounced inspection. The inspection team did not look at all key questions or key lines of enquiry.

We found the following areas that the Trust needed to improve:

  • The Crisis and Home Treatment Team in Norwich was in the process of change and was not consistent in providing safe care. There were occasions when staff failed to visit patients as planned. Staff told us that this was a daily occurrence because they were unable to keep up with demand. The team had a high caseload of patients and this was not managed safely. Contributory factors to the high case load were high staff turnover, vacancies, staff being away on courses, performance management, sickness and a change in criteria for accepting referrals. We found evidence that patients were not being reviewed within the Norfolk home treatment team as per the individual’s agreed safety plan. The Ipswich home treatment team had a caseload of 50; which staff described as unmanageable. The impact in Ipswich was that the quality of care and crisis plans was variable and, at times, poor.
  • Managers had asked staff to change the way they worked. The new way of working did not have a clearly defined policy to give guidance to staff on how to implement the changes. This meant some staff did not understand the reason for change, or how the change would improve patient experience.

  • The Norwich crisis team did not have an embedded approach to learning from when things went wrong.

However:

  • We saw evidence of patients being seen face to face within the four-hour target and where this was breached, there was documented rationale, safety plans in place and patients were kept informed in five of the six records we reviewed. Staff felt that the changes made to facilitate this had a positive impact on patient care.
  • In response to concerns raised regarding Norwich services, the Trust added in extra support and resources to address risks.
  • Some staff felt the trust board were more visible than the previous board and were beginning to listen to staff concerns. We saw action being taken to improve patient experience such as face to face assessments in a timely manner.

3 April to 5 April 2019

During an inspection of Specialist community mental health services for children and young people

We did not rate this inspection.

This was a focussed, unannounced inspection. We found that some progress had been made in all areas, but not enough to be assured that the requirements had been addressed. Therefore, all requirement notices issued in the last inspection remain in place.

We found the following areas the trust needed to improve:

  • Staff had overlooked some patients on the waiting lists and had not followed them up as per the trust’s own procedure. Waiting list data that the trust collected was not always accurate and staff in some services had created their own waiting lists to be assured that information was being captured correctly.
  • The quality of clinical record documentation was poor. Staff did not always update risk assessments following a change in risk and there was limited evidence of detailed crisis plans. Care plans were often written in the third person and did not routinely demonstrate that patients’ voices were heard. Information was not stored on the electronic system in a logical or consistent manner which made it difficult for clinicians to see all interventions and actions in chronological order. Staff were unaware if alerts could be added which would bring concerns such as safeguarding or significant risk to the attention of staff immediately.

  • Some teams still had a high number of vacant posts.This had an adverse impact on waiting times and staff morale.

However:

  • Staff told us that they felt positive about recent changes to key leadership posts and that they were starting to see the impact of these. They felt the trust board were more visible than the previous board and listened to staff concerns. Staff were also positive about their immediate managers. We saw action being taken to improve the patient experience. There were examples of some staff being given delegated responsibility, enabling them to make changes more swiftly.

  • Staff working for the under 14 teams were seeing patients more quickly than had been the case when we last inspected. Those under 14 patients deemed at high risk were being assessed and allocated to a practitioner promptly. There remained a waiting list but we saw evidence of this reducing, with clear plans to continue to act. There were fewer gaps in staffing in the under 14 teams than the Youth teams.

03 to 27 September 2018

During an inspection of Forensic inpatient or secure wards

Our rating of this service stayed the same. We rated it as good because:

  • Managers had completed detailed ligature audits and management plans. The trust had carried out work to reduce ligature risks on the wards.
  • Staff had completed detailed, holistic and person-centred care plans and risk assessments in patient records reviewed. Staff completed full physical health checks for patients on admission and patients had care plans to meet physical health needs.
  • Staff treated patients with kindness and respect. Patients told us that staff were very nice, helpful, open minded and friendly. We observed caring interactions between staff and patients. Staff involved patients in their care plans and risk assessments. Patients could give feedback on the service and their treatment and staff supported them to do this. Patients were involved in staff recruitment.
  • Staff supported patients to meet their goals, and made sure patients had access to opportunities for education and work. Examples included a patient completing a business degree and another working as a volunteer in a café. Patients had access to a recovery college and to light industry workshops on and off site. Staff supported patients to access activities in the community, including sailing, rambling and dog walking.
  • Managers of the service provided strong, local leadership. Managers used dashboard information to monitor and improve the performance of their teams. Team morale was positive. Managers ensured staff were supported in their roles through supervision, team meetings, reflective practice sessions and training.

However:

  • The trust had not ensured robust recording and learning from serious incidents. The trust had not shared learning from a patient death in 2014. There was a patient death in the forensic service in 2017. Both patients died after using the same style of ensuite door as a ligature anchor point. The trust were planning to pilot anti-ligature ensuite doors in new bathrooms but were not replacing existing ensuite doors. Staff had not recorded a serious incident that had occurred on Whitlingham ward in the patient’s progress notes. Details of the incident were not handed over to the next shift. Staff had not updated the patient’s risk assessment.
  • Staff did not always manage medicines and equipment safely. We found out of date medicines and medical equipment on five out of six wards. We found staff had administered as required medicines above prescription limits on two wards and had not always completed medicine administration records on one ward. Staff did not ensure that wards were fully equipped with accessible resuscitation and emergency equipment. Staff were not checking emergency bags and resuscitation equipment in line with trust policy on five out of six wards.
  • Seclusion was not always managed well. The trust had not ensured the seclusion room on Yare ward was free from hazards. Staff did not always follow the Mental Health Act code of practice for patients in seclusion and long term segregation. Reviews and observations were not carried out as required and staff had not instigated seclusion processes for a patient secluded in the courtyard.

03 to 27 September 2018

During an inspection of Community-based mental health services for older people

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

  • Services were unable to offer a full range of occupational therapy and psychological therapies due to lack of staff from those disciplines.
  • The trust was unable to provide numbers of patients waiting and waiting times for access to psychological treatment and told us that they did not currently have a system for monitoring this.
  • The trust had not fully completed the actions from the last inspection. Ligature risk assessments had not been completed for all areas of trust premises. The ligature risk assessments did not capture the risks from all ligature points. The trust had not updated its policy to reflect changes they had made to the risk assessment process. Emergency medication and equipment was not in place at all locations. The Great Yarmouth and Waveney premises did not have an emergency bag at one location and an incomplete bag at one location.
  • Staff felt disconnected from the trust and wider management. Staff felt that the senior trust management were not visible and that the number of management levels between teams and the senior management meant that information passed either way got lost or miscommunicated.

However:

  • The service had sufficient numbers of nursing staff in post to provide safe care for patients. Staff caseloads were manageable and enabled nurses to see patients regularly.
  • Staff completed a risk assessment, comprehensive needs assessment and care plan for all patients following referral into the service.
  • Staff had good communication with GP and community health services to monitor and review patients’ physical health. We also saw good communication with staff at care homes where patients lived, and Great Yarmouth and Waveney team had a dedicated nurse post to work with care homes develop de-escalation techniques and therapeutic interventions.
  • Patients and carers all spoke positively about the care they had received. Patients told us that staff were kind, respectful and supportive. Carers were involved and updated on patients’ care, and received copies of care plans where appropriate.
  • Team leaders had a clear understanding of the service they managed. Team leaders were visible within the service and staff told us that they felt supported by their leaders.

03 to 27 September 2018

During an inspection of Child and adolescent mental health wards

Our rating of this service stayed the same. We rated it as outstanding because:

  • The Unit was exceptionally clean, bright, welcoming and well-maintained throughout. Patients were fully involved in designing and planning the further improvements which were being made to the outside area. Patients were protected by a strong comprehensive safety system: The unit had an up to date ligature risk assessment and staff mitigated risk on the unit by using relational security, positive behaviour plans and staff observation alongside convex mirrors and CCTV. The Unit had a positive, non-hierarchal culture where all staff were encouraged to express any concerns, and a focus on openness, transparency and learning when things go wrong.
  • The Unit had enough nursing staff to provide safe care. Staff found their jobs rewarding and felt valued, respected and supported by the unit manager. One staff member talked about how lucky they felt to work on the unit. Staff were encouraged to pursue personal and professional development opportunities and seek out, and implement, innovative and best practise, for instance by visiting other services and taking advantage of external training. Staff gave up their free time for the benefit of patients, for example by helping to organise a summer fayre.
  • The service provided age-appropriate structured and individualised therapeutic programmes, group activities including wellbeing and exercise, art therapies and education. Activities were offered in the evenings and at weekends. Staff prioritised daily 1-1 sessions with the patients and they had access to psychologists, occupational therapists, a social worker and a family therapist on the ward. The psychologists and family therapist worked across the ward and community to ensure continuity of care.
  • The Unit employed staff to prepare freshly cooked meals on site. Staff discussed with patients their dietary requirements and preferences, including working with them around making healthy choices. The menu was varied and interesting using fresh, locally sourced products. Baking was offered as a therapeutic activity and food tech was part of the education curriculum.
  • Care records were comprehensive, person centred, recovery focused and up to date. Care records showed that patients physical health care needs were assessed and monitored. Patients were fully involved in devising their care plans and were given an updated copy every week. Services were tailored to meet the needs of individual young people and were delivered in a way to ensure flexibility, choice and continuity of care.
  • Staff were knowledgeable about how both the Mental Health Act and Mental Capacity Act applied or not, to the young people they worked with. Staff sought appropriate consent from patients, for example Gillick competency for examinations and treatment. Staff had explained rights to patients detained under the Mental Health Act and repeated these at regular intervals. Patients had access to a social worker and advocacy and knew how to make a complaint if they needed to.
  • The leadership, governance and culture were used to drive and improve the delivery of high-quality person-centred care.
  • Feedback from patients and carers was continually positive. Both a patient and carer said that this was the best child and adolescent unit they had been to, that patients were safe and secure and staff took a collaborative approach and were genuinely caring ‘without exception’. Patients felt truly respected and valued as individuals and empowered as partners in their care, practically and emotionally, by an exceptional and distinctive service.

03 to 27 September 2018

During an inspection of Wards for people with a learning disability or autism

Our rating of this service went down. We rated it as requires improvement because:

  • The wards did not always involve patients in the planning of their care. Care plans did not document mental capacity assessments or best interest decisions. Documentation did not show that patients with communication difficulties were being supported to make decisions about their care.

  • The wards reported higher rates of restraint and seclusion than in the previous reporting period. The room where the service planned to seclude patients in case of emergency did not allow good observation of the room inside. This meant that patients had to be transferred by secure ambulance to another service. The wards did not routinely create positive behavioural support plans.
  • Patients who lacked capacity to give consent to treatment were being given antipsychotic medicines outside of an appropriate legal framework. Staff did not always inform patients who were detained under the Mental Health Act of their legal rights. Staff did not always ensure that Deprivation of Liberty Safeguard paperwork was completed and signed correctly.
  • Staff had raised concerns about the suitability of the ward environment for patients with learning disabilities and had not had a response. Staff felt that the trust vision for the future of their service was not always communicated to them.
  • Staff did not have enough computers to do their jobs.
  • Managers did not measure the performance of their service against other providers.

However:

  • The wards had fully equipped clinic rooms which staff could use for monitoring the physical health of patients. Emergency equipment and medicines were available and checked regularly.
  • The wards had enough nursing staff to provide safe care. Staff completed mandatory training, were supervised regularly and received an annual appraisal. Staff felt respected, supported and valued by the ward manager and had protected time to improve their skills. Staff learnt from incidents by making changes to their procedures. The wards had access to a full multi-disciplinary team and had employed a speech and language therapist since the last inspection.
  • Staff provided patients with a range of activities and treatments to meet their needs and monitored their physical health. Staff used a range of methods to communicate effectively with patients. Patients had their own bedrooms, could meet with relatives privately, and were supported to access activities in the community.
  • Staff supported patients to prepare for their discharge and made a range of information available on the ward in different formats including other languages and easy read.

03 to 27 September 2018

During an inspection of Wards for older people with mental health problems

  • The disconnect between local services and the senior leadership impacted on the ability of the service to offer a safe service. Staff did not feel connected to the wider trust, and the senior managers did not involve service staff in decisions about their services. Staff on wards, including ward level leaders, expressed frustration about senior leadership decisions and that they were not involved in the decision making when they had the specialist knowledge of their environments and risks. Examples of this included trust wide decisions relating to environmental works, such as replacement and reduction of ligature points. While reducing or replacing some ligature points in this service they had created others.
  • Staff described visible local leadership to service manager level, but felt above that role there was a lack of visibility and understanding of the needs of their service. There was a lack of response about issues significant to their wards, such as not supporting ward managers to manage infection control.
  • Ward staff gave examples supporting their opinion that the leadership team had unfairly blamed them for inadequacies on their wards that they had no control.
  • On Laurel ward the controlled drugs keys were not kept safely. They were available to staff even if they were not authorised.
  • There were no processes in place for the sharing of ideas and best practice across the Norfolk and Suffolk teams.

However:

  • Managers had been successful in nurse recruitment for this service, with lower than trust average for vacancies.
  • Staff who had received training in dementia awareness completed a comprehensive mental health assessment for each patient either on admission or soon after. Staff developed comprehensive care plans for each patient that met their mental, emotional, nutritional, and physical health needs. Managers encouraged staff to use new evidence based techniques and technologies to support the delivery of high quality care. Staff used recognised rating scales to assess and record the severity of patient conditions and care and treatment outcomes.
  • Managers recognised the continuing development of staff skills, competence and knowledge as being integral to ensuring high quality care. The mandatory training rate for this service was 92% compared to 88% at the last inspection and higher than the trusts target of 85%. Where mandatory training was not older person specific, ward managers offered supplementary, bespoke training for their staff. Data provided at inspection showed this services’ appraisal rate was 99%, and the supervision rate ranged between 93% and 100% across all wards. The trust target for appraisal and supervision was 89%.
  • Staff treated patients with kindness and respect. Feedback from patients, those who were close to the patients and stakeholders was positive about the way staff treated people. We saw that most staff could anticipate patients’ needs and were able to give help, emotional support and advice when they needed it. Staff supported patients to understand and manage their own care treatment or condition. Staff directed patients to other services as needed, including referral services such as podiatry and dentistry, and supported them to access those services if needed.
  • Managers ensured beds were available when patients needed them. Patients only moved between wards during admission when there were clear clinical reasons or it was in the best interest of the patient. Staff did not move or discharge patients at night or very early in the morning. Managers ensured they did not discharge patients before they were ready.
  • Patients had personalised swipe wrist bands that staff had programmed to allow access to specific parts of the ward. The service had a full range of rooms and equipment to support treatment and care. The Patient-Led Assessments of the Care Environment (PLACE) score for ward food at two locations scored higher than similar trusts which was 91.5%. Willow ward was 99.5%, and Laurel 98.5%, while Rose, Reed, Beach and Sandringham scored 89.4%. The service received five times more compliments than complaints for the period 01 June 2017 to 31 May 2018.

03 to 27 September 2018

During an inspection of Specialist community mental health services for children and young people

Our rating of specialist community mental health services for children and young people went down. We rated it as inadequate because:

  • Not all issues reported at previous inspections had been addressed. We rated safe, responsive and well-led as inadequate. We rated effective as requires improvement and caring as good.
  • The trust had not ensured adequate leadership and governance to address all actions from our 2017 inspection. These related to managing patient waiting times for allocation of care coordinators, risk plans, ligature assessment, supervision and ensuring all teams within the children’s, family and young people’s service were working to common goals and practices.
  • The trust had not ensured a clear overarching strategy and development plan for children’s, family and young people’s services Twenty out of 53 staff raised concerns with us about the management and senior leadership of their service and a lack of understanding of children and young people’s services at board level. This was particularly evident in Suffolk where many staff spoke to us about disconnection from trust decision making; not being involved in changes that affected them and the belief that the trust was Norfolk centred.
  • The service did not have adequate systems for monitoring, assessing and mitigating the risks to patients. The service did not have access to clear information about the number of patients waiting for triage, assessment and treatment across this service. The risk register did not capture all the risks for this service. The service did not consistently meet their target for under 18 routine referrals for assessment or their target for under 18 referrals for treatment. Teams had reported five incidents from June to August 2018 where they had not met commissioned targets for waiting times. There had been five complaints in June to August 2018 about waiting list times. Patients with attention deficit hyperactivity disorder often faced longer waits due to limited resources and system backlogs. Staff did not always record comprehensive risk assessment of patients as we could not find 13 out of 40 records. Staff had not completed crisis plans or advanced decisions for 22 patients. Staff had not developed comprehensive care plans, for nine out of 40 patients. Staff had not always reviewed and updated care plans when patient’s needs changed. Trust data for July 2018 data showed teams were not achieving the trust target of 95% compliance for ensuring records were up to date.
  • Managers did not have easy access to data, which posed a risk they would not have clear information to be able to check how their team was performing. They expressed concern that the systems did not accurately capture information for example data on appraisals, supervisions and staff turnover. Managers did not ensure that Bury South IDT staff received regular supervision. Systems showed 75% compliance with staff appraisal and 70% compliance for staff supervision. A sample of five staff records showed that supervision did not take place regularly with sufficient quality. The trust had not ensured that all staff understood or were following the trust’s complaints policy at South Bury Integrated delivery team. There was no evidence of any trust response to a complainant.
  • The trust had not ensured adequate staffing to meet the needs of the service. This meant patients often waited a long time before receiving triage, assessment and treatment. This posed a risk to patients’ safety. We found examples where patients’ situations had deteriorated and they needed urgent support as they posed a risk to themselves or others. The trust had set up in April 2018 a multi-agency ‘emotional well-being hub’. This team triaged referrals for young people needing health or social care across Suffolk. They were under resourced and had 394 patients awaiting triage 13 September 2018 and it took staff on average 28 days to contact patients and then direct them to the right service. Additionally, the trust had difficulties gaining medical cover for Suffolk to meet patients’ needs which had led to backlogs for appointments. Managers across the trust said there were difficulties recruiting staff. The staff vacancy rate for this core service was 8% as of 31 May 2018. This was higher than the 3% rate reported at the last inspection.
  • The service did not have adequate oversight of ligature risk assessments for premises where staff saw patients. Managers had not completed accurate ligature assessments at four locations. The ligature assessments did not fully capture risks for newly refurbished toilets. This meant staff would not be fully aware of the higher risk areas which needed more supervision. Staff were not following trust processes for infection control as four sites did not have cleaning rotas for treatment rooms and toys. Great Yarmouth and Waveney site had four out of six threadbare chairs in a patient group room, which would be hard for staff to keep clean.

However:

  • Staff were proud of their work and showed commitment to giving a good service for patients and their carers, despite the challenges they faced. Patients and carers told us that when staff gave care and treatment it was often excellent. Staff were non-judgemental and gave patients choices about their care and treatment. Carers gave examples of where staff had gone out of their way to get support for them as well as the patient.
  • Staff delivered care in line with best practice and national guidance (from relevant bodies e.g. National Institute for Health and Care Excellence), for example family therapy, cognitive behavioural therapy and cognitive analytic therapy. Teams such as Great Yarmouth and Waveney youth team had identified clinical pathways and provided information packs to give patients support with trauma, emotional instability mindfulness, hearing voices, self-harm and unusual beliefs. Norfolk teams used ‘patient outcome data’ to check the effectiveness of their service. Staff used technology such as tablets for patients to complete outcome measures such as the ‘revised children’s anxiety and depression scale’ and ‘clinical outcomes in routine evaluation’. The trust had identified research leads and had a research development programme. Staff produced reports sharing information with teams about research relevant to their work.
  • The trust had provided a range of specialist services. These included a service in Suffolk for young people up to 18 years, who were adopted, looked after or in special guardianship, child arrangement or kinship care. This service also offered support to carers or families. The trust had developed a specialist community perinatal mental health service with midwives at Ipswich Hospital and West Suffolk Hospital. The trust had services for patients with an eating disorder or early psychosis. The trust had a youth justice team for patients in contact with criminal justice services. Staff said they had effective working relationships with other teams in and external to the organisation. Examples, included working with local acute hospital and paediatric teams, schools, colleges and universities. Staff made sure patients had access to opportunities for education and work. Staff liaised with schools regarding further observation and assessment to gain a better understanding of children’s needs.
  • The trust had ensured that most staff had completed and were up to date with their mandatory training when we visited. Teams achieved above 80% compliance. The trust had acted following our 2017 inspection to ensure that most staff were competent in the use of the electronic recording system, and staff reported they were confident in being able to use the systems. The emotional well-being hub had recruited a peer support worker and were developing peer support volunteers for 2019.

03 to 27 September 2018

During an inspection of Community mental health services with learning disabilities or autism

Our rating of this service stayed the same. We rated it as good because:

  • All areas were clean and well maintained, with suitable furnishings. The trust had fitted all interview rooms with alarms and staff were available to respond to alarms if required. Staff also had personal alarms when visiting patients in the community. Staff followed the trust wide lone working policy which included clear personal safety protocols.
  • Managers calculated staffing levels to ensure that the service had enough staff with the right skills, qualifications and experience to meet the needs of the patients. The service had sufficient staff to support the patients who used this service which included a psychiatrist. Managers assessed the size of the caseloads of individual staff regularly and helped staff manage the size of their caseloads. At the time of the inspection the service did not have a waiting list for patients accessing the service.
  • Managers identified training needs their staff had and gave them the time and opportunity to develop their skills and knowledge. Staff had completed and were up to date with their mandatory training which included the Mental Health Act, the Mental Health Act Code of Practice and the Mental Capacity Act. Staff received training in safeguarding that was appropriate for their role. Staff could give clear examples of how to protect patients from harassment and discrimination and knew how to make a safeguarding referral and who to inform if they had concerns.
  • Care plans and risk assessments were comprehensive. Staff completed and regularly updated thorough risk assessments for most patients using the service using a trust wide risk assessment tool. Staff embedded completed crisis plans in the risk assessment tool that identified individual patients needs if a crisis occurred. Staff completed comprehensive, personalised, holistic and recovery-orientated care plans, considering the views of the patients, their family or carers. Staff completed a comprehensive mental health assessment for each patient using the service. Staff ensured that patients had regular physical health checks and staff recorded the patients’ physical health problems within the patients care plans and risk assessments. Staff made sure patients had support for their physical health needs, either from their GP or consultant psychiatrist. Staff knew what incidents to report and how to report them. Managers investigated incidents across the trust and if required managers and staff would make changes to practice as a result of incidents and feedback. Managers debriefed and supported staff after any serious incident and fully understood duty of candour.
  • Staff were discreet, respectful, and responsive when caring for patients and their family and maintained confidentiality at all times. Staff gave patients, families and carers help, emotional support and advice when they needed it. Staff supported them to understand and manage their care in their preferred communication method. Staff ensured that easy read documentation and pictorial positive behaviour support plans were in place to support the engagement of the patients and their families or carers.
  • Staff involved patients in decisions about the service. Patients could give feedback on the service and their treatment and staff supported them to do this. Staff enabled families and carers to give feedback on the service they received at individual appointments with patients and via the friends and family test. Feedback from people who use the service, those who are close to them and stakeholders was continually positive about the way staff treated patients. Patients told us that staff were always friendly and welcoming, there was always someone available to offer support and guidance, they felt staff went the extra mile and the care they receive exceeded their expectations.
  • The service met the referral to assessment target in three out of the 13 of the community learning disabilities team. The service met the referral to treatment target in10 out of the 13 teams. The team responded promptly to urgent referrals, we saw examples in care records of patients had been seen on the same day as the referral was made due to them being in crisis.
  • The team tried to engage with people who found it difficult, or were reluctant, to seek support from mental health services. Staff supported patients to maintain contact with their families and carers. Staff told us that carers were central to the care plan for patients and they were often actively involved in patient care. This was evidenced in the patient notes we reviewed.
  • Managers had systems in place to monitor the waiting lists. At the time of the inspection there were no patients waiting longer than 18 weeks for treatment. At the weekly multi agency or multidisciplinary meetings all patients including new referrals were discussed and decisions made on what action needed to be taken for patients to be assessed.
  • Leaders had a good understanding of the services they managed. They could explain clearly how the teams were working to provide high quality care. Local managers had systems and procedures to ensure that the premises were safe and clean; staff received training and supervision staff assessed patients and treated them well; referrals and waiting times were managed well; incidents and complaints were reported, investigated and learned from with findings shared with all staff.
  • Managers understood their teams and identified when staff needed extra support. They discussed with the staff member what they could do to enable the individual staff member to perform their job well. Managers supported staff through regular supervision and appraisals and held monthly staff team meetings. In addition to this, managers supported staff during their appraisals and discussed career progression and development during management supervision. Managers used team meetings and protected time to allow staff to discuss how to improve the service and innovative ways of working. This resulted in managers developing the weekly multiagency meetings and changes to the environment.

However:

  • Some staff that we spoke with did not feel the same support or respect from the senior management team across the trust. Staff told us that they felt they were ‘left alone’ to get on with their work. They felt senior management were not aware of the positive work and changes they had made in order to improve the service for patients. In addition to this staff reported that the did not feel included in discussion about changes outside of this service and across the trust.
  • We were concerned that these issues when reported to the trust’s senior management were not acted on in a timely manner.

03 to 27 September 2018

During an inspection of Mental health crisis services and health-based places of safety

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

  • The trust did not have sufficient oversight of key risks and issues for this service. Environmental risk assessments did not identify all risks and some identified risks in assessments rooms and the HBPoSs had not been removed or reduced. Staff awareness of environmental risks varied. Repairs were needed to ensure one of the assessment rooms provided privacy and dignity for patients. Staff had identified this risk and reported this repeatedly but repairs were still awaited at the time of our inspection.
  • Staff did not always manage referrals according to the level of urgency identified by the referrer, or keep accurate records to support the decisions made. Within the Suffolk services, we found that staff were downgrading a high proportion of the emergency and urgent referrals; resulting in some urgent referrals waiting for up to and exceeding 28 days for a telephone contact. Staff had not maintained clear records to support the decisions made and we found records were often incomplete and difficult to follow. The trust had not consistently met its target times for four-hour emergency referrals.
  • Some services still had staffing shortages, particularly at night. There was no oversight of the sharing of lessons learned from when something goes wrong between teams or localities and key recommendations from serious incident reports did not translate into trust wide learning. Senior managers were unable to demonstrate any evidence of how lessons learnt are shared between teams.
  • The lack of strategic direction for the core service identified in our inspections in 2014, 2017 and 2018 remained. Despite the introduction of a standard operating procedure for crisis resolution and home treatment teams, differing practices, staffing levels and inequitable delivery of services were observed between teams. For example, patients received a different response for the four-hour emergency assessment between Norfolk and Suffolk services. We were concerned that patients residing in Norfolk did not receive an equitable service to those residing in Suffolk.
  • Issues raised in our previous inspections relating to leadership and engagement remained. Some staff reported a recent increase in the visibility of senior leaders in some services but most staff we spoke with told us that the senior leaders were out of touch with what was happening on the front line and did not understand the risks and issues experienced by the staff themselves. Staff told us they had not had the opportunity to contribute to discussions about changes to their services.

However

  • Staff were caring and all patients told us that they felt positive about the care they received from staff. Leaders at a local level had the right skills, knowledge and experience to lead their teams. They had a clear understanding of the service they managed and displayed passion for their services.
  • Staff completed a comprehensive mental health assessment of each patient. Overall, care plans were up to date, personalised, holistic, recovery orientated and considered physical health needs.
  • Improvements had been made in the number of staff who had had appraisals and mandatory training since our last inspection. Improvements had also been made in staffing levels at the HBPoS and staff working there had received specific training on their role and were knowledgeable about their roles and responsibilities.

03 to 27 September 2018

During an inspection looking at part of the service

Our rating of the trust stayed the same. We rated it as inadequate because:

  • The trust board and senior leadership team were in transition and had not formed to deliver a service that provided high-quality sustainable care. At our inspection of 2017, we had significant concerns about the safety, culture and leadership at the trust. We told the trust that they must urgently address concerns and meet regulation. At this inspection, we found that some of our significant concerns, some that we had raised with the trust in 2014, had not yet been fully addressed. We found that the board had not driven effective change at a pace and with sufficient traction to bring about improvements needed to resolve the failings in safety and to bring about sustained improvement.
  • When we last inspected, we told the trust leadership that they did not demonstrate a safety narrative running through the organisation and that that they should ensure that learning was captured from incidents and concerns. At this inspection, we found that the safety culture has not yet fully developed. Managers did not ensure that learning from incidents was shared and embedded across the trust. Not all ward and community environments were safe. The quality of environmental risk assessments varied across services. Not all clinical risks were managed. Staff did not manage medicines and equipment in a safe way. Patients in seclusion did not always have access to the appropriate reviews of their treatment. Vacancies remained high particularly for nursing and medical staff. The trust had not ensured there were enough staff in some community services to meet the needs of patients. All of these issues had been raised with the trust during previous inspections.
  • We found widespread low morale across services. This was attributed to a “do unto” attitude staff felt came from senior management and directors.
  • The trust was attempting to take a systematic approach to governance but this had not fully succeeded in bringing about an improvement to the quality of services or ensured that these delivered a high standard of care. The trust had developed systems for identifying risks and was planning to eliminate or reduce them, but these were not yet effective in coping with both expected and unexpected risks. At this inspection we found that key risks that were considered closed or mitigated had not been fully addressed. In some cases, work undertaken had created new risks. These included ligature point management, care planning, access and waiting lists, staffing levels and seclusion practice and environments. It is concerning that the trust’s own assurance process had indicated more progress in some areas than we found at this inspection.
  • We were very concerned about access to services and the management of the many patients who are on waiting lists. Not all services were meeting their targets for assessment. We were not assured that the trust responded appropriately to emergency or urgent referrals. Too many referrals were handed off inappropriately or refused and downgraded from urgent to routine without due care. We found many instances of people who had significant needs who were denied a service. Records showed that some patients had harmed themselves while waiting for contact from clinical staff'. Bed management remained challenging particularly in acute services. The planning of patients’ discharges did not always contribute to people staying out of hospital.

However:

  • Staff treated patients with compassion and kindness. They respected patients’ privacy and dignity, and supported their individual needs. We observed positive interactions and saw staff responding to individual patient need. Staff usually involved patients and those close to them in decisions about their care and treatment.
  • The service provided mandatory training in key skills to all staff and made sure everyone completed it. Managers made sure they had staff with a range of skills needed to provide high quality care. They supported staff with appraisals, supervision, and opportunities to update and further develop their skills.
  • Staff assessed the mental health and physical health of patients on admission. Staff supported patients with their physical health and encouraged them to live healthier lives.
  • Access to the clinical information system had improved. Work was underway to improve the forms and assessment documents that staff needed to complete for patients.
  • The trust has committed to improving services by learning from when things went well and when they went wrong, and has begun to promote training, research and innovation. The trust had participated in some national improvement and innovation projects and undertook a wide range of quality audits and research.

03 to 27 September 2018

During an inspection of Acute wards for adults of working age and psychiatric intensive care units

  • Safety was not a sufficient priority. The trust had failed to address all issues raised from previous inspections dating back to 2014. Not all ward environments were safe. The quality of environmental risk assessments varied across wards. Managers had not identified all the risks contained within their environments. Staff did not manage medicines and equipment in a safe way. The trust missed opportunities to prevent or minimise harm. Senior managers did not share lessons learned effectively and there was a lack of addressing themes from incidents quickly. Wards worked below the established numbers of staff required to keep patients safe. Patients in seclusion did not always have access to the appropriate reviews of their treatment, or the appropriate staff to maintain their dignity.
  • Patients were at risk of not receiving individualised treatment. Staff did not involve all patients in their care plans. Twenty-three patients could not describe what their care plan said and what goals they were working towards. Staff used templates for care plans which meant goals, actions and interventions were the same for patients. Care plans were not person centred and lacked patient voice. Not all patients had access to a copy of their care plan. Staff did not always involve people patients identified as important to them in their care. On 20 occasions staff did not update families and carers when they secluded patients. We specifically requested one carer be updated about their loved one’s care when we identified inappropriate delays.
  • Staff did not plan patient’s discharge from hospital effectively. Staff created discharge plans that did not provide robust detail and patients expressed concerns about their discharge plans. The service reported 253 readmissions within 28 days between 1st June 2017 and 31st May 2018. Of these there was an average of 11 days between discharge and readmission. Staff admitted 18 of these patients the day following discharge.
  • The leadership, governance and culture of the organisation did not assure the delivery of high quality care. There continued to be issues raised from previous inspections that the trust had failed to address. Staff in services reported a distinct lack of connection to the wider organisation. Staff described a lack of collaboration in decisions that affected their wards and felt the trust priority was not patient care. Staff reported a lack of visible leadership from the most senior managers in the organisation. The trust did not have sufficient oversight of key risk issues and failed to identify key themes and trends to prevent serious incidents from re-occurring. The trust did not learn from previous lessons and did not share information about incidents effectively. Assurance tools, such as clinical audits, were not accurate.

However:

  • Local ward staff demonstrated passion and commitment to their roles. Teams created ways to support each other, despite challenging circumstances with staffing and morale. Managers ensured staff had access to regular supervision and appraisals to discuss their workload, training and development needs. Staff had the right qualifications and experience required to support patients and we observed positive and caring interactions.
  • Staff ensured that patients had access to appropriate physical healthcare. Physical healthcare nurses worked with teams to meet the physical healthcare needs of patient’s and to provide ongoing monitoring of physical health conditions.
  • Local ward staff gave patients the opportunity to provide feedback through community meetings and ward forums. Where patients needed support to express their views, staff referred them to advocacy services.

03 to 27 September 2018

During an inspection of Community-based mental health services for adults of working age

Our rating of this service stayed the same. We rated it as inadequate because:

  • During this inspection we found major concerns about access to services. We were not assured that the adult community mental health services responded appropriately to urgent referrals. We found that staff in Suffolk access and assessment team were downgrading a high proportion of the emergency and urgent referrals. We saw numerous situations where people were not offered a service yet had been in significant need. Records showed that, in some cases, patients had self-harmed or taken overdoses whilst waiting for contact. The trust did not consistently meet the target to see patients from referral stage to assessment. For routine referrals, this was 78% against a target of 95%. From assessment to treatment the target was 18 weeks. At the time of the inspection, there were 224 people waiting longer than 18 weeks for treatment.
  • We were particularly concerned about the risk management of community adult patients awaiting allocation of a care co-ordinator. At the time of inspection, a total of 2390 patients were without a care coordinator or lead professional across adult services. During this waiting period patients only received telephone calls and no face to face contact. This meant there was very little support for those patients for varying lengths of time, and the impact of these arrangements raised serious safety issues for patients in this position. Since the last inspection, the trust had implemented a system that required that all red rated cases were allocated a care coordinator immediately and not held on the waiting list. However, at one service we found unallocated patients on the waiting list for a care coordinator and they were red status. Three patients care and treatment records had changed in risk, and staff had not changed the RAG rating to reflect this. We found a patient who had been raised to amber however, staff had not documented why, and there had been no contact from April to July 2018.
  • There was a lack of oversight of adult community mental health services by the wider trust. For example, we found a gap in shared feedback and learning from incidents across the whole trust. Since June 2018, there had been further deaths. We found evidence that recommendations had been made following many investigations at the trust but there was a lack of evidence that the trust had acted on all recommendations. This was in relation to risk assessments and care plans not completed and up to date and the number of people on waiting lists for allocation of a care co-ordinator. We found evidence that these problems were still present despite these recommendations
  • Staff told us that information was cascaded down to service level from the trust board without engagement. Staff told us that there was poor leadership above local manager level and that recognition and acknowledgement for good work was poor. Staff did not feel that they could contribute to the trust strategy. Some community services said they felt isolated from the rest of the trust. Patients and carers we spoke with told us that the senior leadership was detached from local services and did not involve them or listen to their views.
  • The trust had not fully carried out its intention to assess ligature risk in community bases and, despite raising it at the last inspection, staff were not fully assessing risk. Not all community settings had an adequate ligature point risk assessment. This meant staff at these locations were not aware of specific risks. Additional risks had been introduced in patient’s toilets following works to make the environment safer.

However:

  • Staff were very clear about the personal safety protocols within the community teams, and the trust policy for lone working. Staff could explain to us the system to ensure administration teams were aware of their location. Staff at all sites visited had personal alarms in working order, and regular checks of the equipment carried out and documented.
  • Ninety four percent of staff had received training in safeguarding that was appropriate for their role. Staff demonstrated clear knowledge of trust safeguarding processes and procedures, and recognised the different types of potential abuse.
  • Statutory records inputted by staff were complete and in order on the electronic system. We examined 51 medication records. Medication records for the 18 patients with a community treatment order, were in place. These areas had improved since the last inspection.
  • Managers identified any specialist training needs their staff had and gave them the time and opportunity to develop their skills and knowledge. Managers made sure staff received any specialist training for their role. For example, the nurse training pathway, psychology, mental health professionals and trauma training was ongoing by staff at community services.
  • We observed and heard staff treating patients with kindness, dignity, respect and support. Staff demonstrated commitment and were caring towards patients. Staff offered practical and emotional support to family’s and carers. Patients we spoke with were complimentary about their care coordinators. We saw evidence of information given to patients to help them understand their acre and treatment needs, we saw medicine and conditions advice in easy read formats for patients to understand.
  • Managers and staff at community services made “your service your say” and “help us to help you” feedback leaflets easily accessible to patients across community sites in waiting areas.

03 to 27 September 2018

During an inspection of Long stay or rehabilitation mental health wards for working age adults

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

  • We observed a lack of learning from lessons or action taken from audit or incidents. There had been overall improvement in collating raw data, but this was not always translating into improving standards. We saw audit had been completed but conclusions and findings of the audits were not always turned into action.
  • The ward only accepted patients with low risk of self-harm or violence onto the ward. This was not the criteria reflected in the operational policy of the trust. It was not clear how the needs of the higher risk patient group were met, if rehabilitation was an identified clinical need. The policy referred to the service as an open rehabilitation environment but failed to specify the type of service as per best practice guidance. The operational policy required review.
  • We continued to see information stored in different places in the electronic care records. This meant that staff had to spend a lot of time finding the information they needed to do their jobs. We saw the trust had invested to improve capacity and efficiency and although the system froze fewer times than during previous inspections, it remained a concern.

However:

  • Staff were pro-active in discharge planning and ensured patients views were at the centre of the process. This was an improvement from previous inspections.
  • We saw that patients had access to local community services and were actively encouraged to access work and educational courses. There was also a strong occupational therapy presence to support patients with activities of daily living.

15 to 30 May 2018

During an inspection looking at part of the service

When aggregating ratings, our inspection teams follow a set of principles to ensure consistent decisions. The principles will normally apply but will be balanced by inspection teams using their discretion and professional judgement in the light of all of the available evidence.

We found the following issues that the trust needs to improve:

  • Patients did not benefit from safe services in all areas. The breaches of regulation identified at our previous inspections had not all been resolved. Also, the board needs to take further and more timely action to address additional areas of improvement.
  • Performance information and data had not yet facilitated effective learning or brought about improvement to practices in all areas. Work had been undertaken to better capture risks and a clearer governance structure had been put in place with clearer lines of accountability. However, further work is required to meet the recommendations of a recent governance review of the trust.
  • The trust had not ensured that all risk assessments and care plans were in place, updated consistently in line with changes to patients’ needs or risks, or reflected patients’ views on their care.
  • Staffing was not sufficient in community mental health teams. Patients across the trust had not all been allocated a care coordinator following assessment. We were concerned that the procedures that managers had put in place were not sufficient to mitigate this risk.
  • Patients were still not always secluded safely or within appropriate environments. Ward staff were not meeting the standard for recording and monitoring of patients in seclusion.

However, the trust had addressed some of concerns that we raised at the previous inspection:

  • The trust had ensured that alarms were available to staff and that staff had access to a defibrillator and life support training.
  • The trust had made appropriate arrangements to manage mixed sex accommodation.
  • Overall mandatory training and appraisal had rates exceeded the 75% compliance target.
  • Some progress had been made in relation to recruiting additional staff to the wards and crisis teams and staffing levels were sufficient at the time of our inspection.
  • Some seclusion rooms were now meeting standards.

10 July 2017 – 20 July 2017 and 25 July 2017

During an inspection of Mental health crisis services and health-based places of safety

We rated Crisis services and Health Based Place of Safety as ‘requires improvement ‘because:

  • The last CQC inspection highlighted a number of concerns the trust was required to address. During this inspection we found improvements were still needed to ensure compliance with regulations in a number of areas, for example, compliance with mandatory training for some key subjects, staff receipt of supervision and appraisals, staff availability to support patients in the HBPoS at Fermoy, and compliance with key performance indicators and trust policy for assessment of emergency referrals within four hours.

  • Some services had staffing shortages particularly at night. In some services all shifts were not covered at night and lone working practices could not always be followed. At the HBPoS Fermoy Unit, staff were not available to take responsibility for patients detained under section 136 by police and patients did not receive physical or physiological observations.

  • Many staff were not in receipt of regular supervision and the trust has no effective oversight to monitor compliance at a local level. There were low levels of compliance with some key mandatory training. Not all staff had received an annual appraisal in line with the trust target and there were gaps in staff supervision across most teams.

  • The trust continued to have no overarching operating procedure for crisis services that clearly defined key performance indicators (KPI) and targets for the services. Across most teams, team managers were not able to provide detailed KPI data, which affected their ability to monitor service performance effectively. Data provided by the trust for KPIs was unclear and inconsistent.

  • Crisis services were not consistently meeting the trust target for response to emergency assessments. The response to crisis calls out of hours was inconsistent in one service. The crisis line for people not open to mental health services was not easily located on the internet, meaning people might not easily locate the contact number when needed.

  • The length of time from admission to a health based place of safety to commencement of a mental health assessment was not always within the three hours target set by the trust and its partners and as recommended in the MHA Code of Practice.

  • Environments in some interview rooms were not fit for purpose for assessing patients experiencing a mental health crisis. At the Fermoy Unit, staff managed the risk by remaining with patients while they were on site and for high risk patients, two staff were present.

  • There was no alarm system in one crisis service and staff used personal attack alarms when seeing patients, which did not show their location if the alarm was activated.

  • The storage of medication in one service did not meet best practice.

However:

  • Improvements had been made to the environment of the health based places of safety. Ligature risk assessments had been completed and regularly reviewed.

  • Risk assessments were completed for all patients and in most cases updated as the level of risk changed.

  • Physical healthcare monitoring was taking place where needed. Overall, improvements had been made in the physical healthcare monitoring of patients in the health based places of safety.

  • People told us staff treated them with respect, listened to them and were very professional and caring. They were involved in their care and treatment and were aware of their care plans. Most patients had care plans that considered all their circumstances and were centred on them as an individual.

  • Staff communicated effectively with patients and were compassionate. Staff were very positive about team working and the mutual support they gave one another. They felt well supported by their immediate managers.

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10 to 20, and 25 July 2017

During an inspection of Acute wards for adults of working age and psychiatric intensive care units

We rated acute wards for adults of working age and the psychiatric intensive care unit overall as ‘inadequate’ because

  • We had concerns that significant quality and safety risks still remained for patients and others. The trust board were slow to take adequate action to ensure that breaches of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 identified from our 2014 and 2016 inspections were completed. For example, actions were still needed to reduce environmental risks such as ligature points and line of sights on wards.
  • Staff records and checks of patients in seclusion were not always completed, which we had identified at our last inspection. The trust's provision of seclusion rooms on some wards was not adequate.
  • Staff were still being trained to use prone restraint (face down) to give rapid tranquilisation injections. This is not in line with best practice guidance.
  • The trust had not taken adequate steps to ensure staffing vacancies did not impact on the service and patient care. Staff had reported 406 incidents where this had impacted on the service or patient care. Staff did not receive regular supervision.
  • We found examples of patients’ risk assessments and care plan records not being updated and gaps in the monitoring of patients physical health care needs. The trust Mental Health Act 1983/2007 administration oversight was not effective as two patients detention under the Act had expired.
  • The trust’s oversight and management of patient admissions and discharges was not effective. A high number of patients were placed out of trust and area; this had increased since the last inspection. Staff moved patients regularly between wards during their treatment and this was not always for clinical reasons. A notable amount of patients faced delays for their discharge or were readmitted soon after.

However

  • Most patients said they felt safe on wards and spoke positively about the care and support staff gave them. Patients and carers told us staff involved them in their care and treatment.
  • Staff gave examples of how they supported patients with diverse needs. There were systems for patients to raise concerns or complaints and have staff respond to them.
  • Staff reported good morale and efficient managers at local level. There were examples of effective multi -disciplinary team working. Staff gave us examples of how they were supported to progress with their career and take on new roles and responsibilities. Staff said senior staff were more approachable and responsive since our last inspection.
  • Staff gave examples of learning from incidents to reduce reoccurrence and of safeguarding patients.
  • Staff gave examples of improvements made to the quality of the service through introduction of the ‘safe wards’ model of care.

10 - 20 July 2017

During an inspection of Community-based mental health services for older people

We rated community-based mental health services for older people as requires improvement because:

  • Some of the concerns identified in the last inspection report as requirement notices had not been addressed by the trust.

  • The trust had not reviewed the core staffing levels including the availability of consultant psychiatrists within this service despite the concerns of front line staff in Ipswich. Not all caseloads were manageable particularly in the Bury South West Suffolk IDT. Caseloads in this team were an average of 60-70 with an average of 90 referrals per month. Staff were not able to see urgent new patient referrals within 24 hours, as per the trust’s own performance target.

  • Risk assessments were inconsistent and were not all completed or updated. Some staff recorded patient risk in continuation notes, rather than in the specific risk assessment section.

  • The wider trust had not addressed the identified concerns relating to the condition of treatment environments and ligature risks across at all services where patients attended for treatment.

  • The trust’s electronic recording system was unreliable, when visiting the Bury North DCLL we found that the system had crashed, which meant staff could not access patient treatment information and risk assessments.

  • Concerns were identified with all clinic rooms including out of date and uncalibrated equipment. Six of the clinic rooms inspected did not hold emergency medication for use on site or in the community, but continued to administer injections.

  • Automated external defibrillators (AED) had been removed by the trust for these services but front line staff lacking knowledge of the alternative arrangements in place.

  • Alarm pull cords in some accessible toilets were not working and staff did not appear to know how to respond when these were pulled. Personal safety alarms for staff did not work at Great Yarmouth and West Norfolk CMHS sites.

  • Thirteen care plans reviewed in detail were generalised and had the same outcome goals. This meant that these care plans were not patient centred.

  • In the Norfolk DCLL team at Chatterton House, consultant psychiatrists only saw the most complex patients. Psychiatrists mostly reviewed the GP scan results to form a diagnosis and would then prescribe medication without a face to face consultation.

  • The trust did not provide data relating to supervision for this core service prior to the inspection. Service managers were unable to consistently assure us through data recorded that staff received regular clinical or managerial supervision. It was therefore unclear how training and performance issues were identified and robustly managed.

However:

  • There was a clear trust lone working protocol in place. Staff used the buddy system based on a risk assessment of the individual patient and their family.

  • Staff knew what incidents to report and we saw evidence of trust wide learning from these across the service.

  • Managers monitored the patients on the waiting list to identify any increases in patient’s level of need. These patients would then be prioritised by staff.

  • Patients had access to psychological therapies, some teams had a psychologist and they delivered a cognitive stimulation therapy group, which was an evidenced based treatment for people with dementia. Trust staff referred some patients for additional psychological therapies to the wellbeing team.

  • Patients said that staff were kind, caring and respectful towards them and took time to listen to them. Several patients spoke highly of their own care co-ordinator and could not thank them enough.

  • Managers addressed complaints in a timely manner. Examples were seen of staff being open and honest with the patient and their family.

10 - 20 July 2017

During an inspection of Community-based mental health services for adults of working age

We rated community-based mental health services for adults of working age as inadequate because:

  • Concerns were identified with all clinic rooms. These included out of date equipment. Equipment not calibrated or safety checked. Inconsistent clinic room and fridge temperature monitoring, with a lack of robust systems in place for the monitoring of safe medication storage.

  • Automated external defibrillators (AED) were removed by the trust for these services, with front line staff lacking knowledge of the alternative arrangements in place.

  • We found six of the clinic rooms inspected did not hold emergency medication, but continued to administer injections.

  • There was a 59% completion rate for staff appraisals for community adult services; however, we identified one service with a completion rate of 27% (Bury South ECP). It was therefore unclear how training and performance issues were identified and managed.

  • Service managers were unable to consistently assure us through data recorded that staff received regular clinical or managerial supervision .Some service managers held spreadsheets to monitor completion. The trust did not provide data relating to supervision prior to the inspection.

  • Only four teams achieved the trust’s 90% or above compliance target for mandatory training.

  • Ligature risk audits were out of date, or lacked detail to enable staff to manage and mitigate risks to patients accessing services for treatment.

  • Personal safety alarms for staff did not work at the Great Yarmouth and West Norfolk CMHS sites inspected placing staff at potential risk. This was not in line with lone working practices.

  • There was variable quality of recording of patient records including care plans, risk assessments and crisis plans with inconsistent details regarding drug sensitivities and health care monitoring.

  • Community adult services were 28% over capacity in relation to the number of referrals received, and staffing levels to meet those needs. Norfolk service managers had submitted a joint report to the trust board and this concern was on the trust risk register. At the time of the inspection, these concerns had not been addressed.

  • There were high patient waiting lists in some teams, with inconsistent practices in place to robustly manage the risk for those patients awaiting allocation of a care coordinator, access to services or treatment.

  • Some staff reported allegations of bullying cultures within the management teams, and reluctance to implement whistleblowing procedures for fear of reprisals.

  • Community adult services had staffing vacancies of 9% and 4% sickness levels; with 2954 shifts covered by agency qualified nurses between 1 April 2016 and 31 March 2017. Core service sickness rates were below the trust average of 5% and turnover rates were in line with the trust average of 12%.

  • Patients received substandard levels of physical health care monitoring, with staff acknowledging this was as a result of workload pressures.

  • Services held patient waiting lists varying in size from 3 to 141 patients. There were inconsistent practices for the management of risks associated with waiting for treatment and allocation to a care coordinator. Based on waiting list numbers provided during the inspection, there were approximately 473 patients on waiting lists who did not have an allocated care coordinator.

  • Alarm pull cords in some accessible toilets were not working and staff did not appear to know how to respond when these were pulled.

However:

  • Staff interacted with patients and their family members with care and compassion. Staff spoke about the patients on their caseloads with knowledge of their needs, social and medical histories. Staff offered practical and emotional support to carers and family members.

  • Staff treated patients with respect, and showed professionalism when handling challenging situations.

  • The trust scored 93% in the May 2017 friends and family test for patients who would recommend the service. This was an improvement from the previous year when the trust scored 62%.

10 to 20 July 2017

During an inspection of Wards for people with a learning disability or autism

We rated wards for people with learning disabilities and autism as good because:

  • Patients had access to activities seven days a week. A Pets as Therapy dog came to the ward every week and patients told us they looked forward to this. Patients were able to personalise their bedrooms and they had somewhere secure to store their possessions.

  • Shifts were covered by a sufficient number of staff of the right grade and skill mix which enabled staff to maximise shift-time on direct care activities. Staffing levels were sufficient for patients to have 1:1 time with their named nurse every day. Staff knew how to make safeguarding referrals and what constituted abuse. The ward manager had sufficient authority and administrative support within the team.

  • Staff showed understanding of patients’ needs in an individual and person-centred way. We observed staff interactions with patients to be caring and staff were respectful at all times. Patients were able to get involved in decisions about their service through regular patient meetings and staff fed back to patients when issues were raised.

  • Environmental risk assessments were undertaken regularly and updated when required. Ward areas were cleaned twice daily and the environment was comfortable, well-maintained and with good furnishings.

  • There were effective handovers within the team and with other teams in the trust as well as local authority social services. The multidisciplinary team, consisting of psychologist, social worker, nurses and doctor, met three times a week. Staff were supervised regularly and had weekly team meetings.

  • Patient accessible information was on display about patients’ rights, how to complain and advocacy. There was a choice of food and the daily menu was displayed in the dining room using patient accessible information.

  • There was a full range of rooms and equipment to support treatment and care including a low stimulus room. Patients had access to extensive outside space with quiet areas.

  • Staff were trained in the Mental Capacity Act and had a good understanding of how to apply this knowledge. Staff accessed the policy on the intranet and sought advice from the team’s social worker and manager.

  • Care records were holistic, person centred and risk assessed.

  • Staff said morale was high and teams worked well together. Staff knew how to whistle-blow and felt able to raise concerns without fear of victimisation. Staff members were able to submit items to the Trust risk register.

  • Mandatory training compliance was 89% and there were opportunities to undertake specialist and leadership development training.

However:

  • Access to speech and language therapy assessments was problematic, confusing and patients experienced long delays. One patient was on the waiting list in the community for six months without being seen (Suffolk West). After the patient was admitted to Walker Close, they experienced a choking incident. Staff made an urgent referral but still waited a further two months before the patient was seen by a speech and language therapist from another team.

  • Minutes from team meetings showed actions but no outcomes so it was not possible to determine whether these were followed up. Some notes were vague and did not include discussion details or attendees so were not useful for team members who were unable to attend.

  • Six patient discharges over a period of twelve months were delayed due to a lack of suitable placements.

  • There were ligature risks in the bathroom of Bungalow 3 as basin taps were not anti-ligature.

10 to 20 July 2017

During an inspection of Community mental health services with learning disabilities or autism

We rated Norfolk and Suffolk community mental health services for people with a learning disability or autism as good because:

  • The trust had invested in anti-ligature fittings in all the team bases (ligature points are where something can be tied in order to self- harm). The trust had ensured that ligature points across the sites were recorded on the environmental risk registers.

  • The community services were situated in accessible areas. Standards of décor and furnishings varied across locations from good in Mariner House to basic in Waveney and Bury south integrated delivery team. There was a range of rooms at all sites that were used for interviews, activities and staff meetings. There were no alarms at the Waveney locations and staff did not carry personal alarms.

  • Links with the local GP surgeries and other agencies were robust. Staff worked well as part of the wider integrated delivery teams at each community site as well as within their own multi- disciplinary teams.

  • All patients had a care co-ordinator when under the care programme approach.

  • Staff caseloads were manageable.

  • Staff knew and applied lone working and safeguarding policies as part of their day to day work.

  • The trust had clear referral and assessment processes. Assessments were comprehensive and included both current and historical information.

  • Staff talked knowledgeably about issues of capacity and could give examples of when they applied this knowledge.

  • Patients attended individual care reviews to discuss their care wherever possible. When a patient was assessed as lacking capacity, this was documented. Decisions regarding patient care were made following consideration of the patients’ best interests.

  • Staff morale was consistently high across the range of staff roles.

  • Staff received managerial 1:1 and group clinical supervision monthly.

  • Ongoing professional development was embedded within the learning disability teams.

However:

  • The trust had not ensured that patients did not have an excessive wait to access specialist services such as speech and language therapy. Access to speech and language therapy, including for dysphagia assessments, remained inconsistent. This was a requirement of the last inspection in 2016. Patients and families continued to experience excessive waiting time to access speech and language therapy.

  • A disparity existed in terms of access to specialist healthcare input dependent on where a patient lived.

  • The variety of healthcare professionals available to support patients within teams differed.

  • The trust had not advertised for a replacement to the consultant psychiatrist post in Ipswich. Some staff expressed grave concerns regarding the potential lack of consultant psychiatrist availability for this team.

  • The child and adolescent community mental health team for people with learning disabilities or autism carried a low staff to patient ratio.

  • Staff had not always recorded whether or not a copy of the care plan had been offered to the patient.

  • Physical healthcare records were not easy to find or were missing in the notes.

10-20 July 2017

During an inspection of Specialist community mental health services for children and young people

We rated specialist community mental health services for children and young people as requires improvement because:

  • Ligature audits were either not present or incomplete in some teams.

  • We had concerns in relation to patients safety at Thurlow House. Treatment rooms were not fitted with alarms and staff were not using personal alarms to summon help if required.

  • The waiting rooms were used by young people and adults which was a potential safeguarding risk for children and young people. The trust partially addressed this issue at the inspection.

  • At Thurlow House the administration area, interview rooms and rooms used for group session were not sound proofed. During the inspection we overheard confidential conversations relating to patients who use the service. We were concerned that patients were in these areas and could have heard these discussions too which is a breach of confidentiality.

  • Staff had not completed 15 of the 44 risk assessments in full on the electronic recording system.

  • The quality of care records we reviewed was variable, and dependent upon how confident and knowledgeable the staff member felt about using the electronic system.

  • Recording of supervision was not centralised or standardised; supervisors were using different recording systems and tools across the service.

  • In Suffolk there was one family therapist compared to seven in Norfolk, and no play therapist in Suffolk while there were five in Norfolk. This meant that Suffolk could not provide play therapy and had longer waiting lists for family therapy than in Norfolk.

  • Teams were working in isolation of each other. This meant the service was not cohesive, and that lessons learned and good practice in the service was not being shared across the trust.

  • Staff and doctors were only carrying out basic physical health checks, such as blood pressure, height, and weight on those patients receiving medication.

  • There were waiting lists for allocation to care co-ordinators ranging from three weeks to eight months, and a seven-month wait for psychology.

  • The staff we spoke with did not have a full understanding of the access criteria for children and young people.

  • Ten staff and managers told us they were unclear about the overarching strategy and development plan for the children, family, and young people’s service in Norfolk and Suffolk NHS.

  • Not all managers were working to the same key performance indicators and governance systems such as monitoring supervision, training, and monitoring of waiting lists were not centralised.

  • Managers did not ensure that staff completed a compliance level for all mandatory training of above 75%.

  • Managers had not ensured that they had addressed the issues that were raised in the inspection carried out 2016.

However:

  • Managers had been creative in addressing their staffing issues.

  • Managers had introduced new systems for managing referrals and monitoring people on waiting lists.

  • Patients waiting for care coordination had face-to-face initial assessments and eight weekly follow up reviews by the MDT team.

  • Staff were following robust safeguarding processes, including joint working with other agencies.

  • We saw evidence of effective handover between services within the organisation, such as community to crisis team or inpatient services.

  • Patients and carers spoke positively about the flexibility of the services, the knowledge and skills of staff to explain difficult concepts, and the trustworthiness of the information staff gave them.

  • Services we visited were meeting their referral to assessment targets.

  • Patients and carers waiting for care co-ordinators were offered regular support including brief intervention therapies based on skills training, manging stress and coping strategies.

  • Staff reported that local level management was good. There were opportunities for professional development, and a stronger focus on regular staff support through clinical and managerial supervision, including opportunities for upskilling.

  • Reporting and learning from incidents, and sharing this learning within individual teams was effective.

10-20 July 2017

During an inspection of Child and adolescent mental health wards

We rated child and adolescent mental health wards as outstanding because:

  • Managers had addressed issues that were highlighted during the inspection carried out in 2016 in relation to prone restraints, ligature assessments and levels of staffing.

  • The unit was exceptionally clean and well maintained throughout. The unit had an up to date ligature risk audit, staff mitigated the risk on the unit by observing patients.

  • There were separate sleeping arrangements for male and female patients that complied with the Department of Health and Mental Health Act 1983 (MHA) Code of Practice guidelines on eliminating mixed sex accommodation.

  • Doors were labelled with whose office it was on unit room doors, for example - occupational therapist. This meant patients could easily contact clinicians on the unit.

  • The trust had a named safeguarding lead for patients. Staff were trained in safeguarding and knew how to make a safeguarding alert.

  • In line with trust policy, staff only used physical restraint in exceptional circumstances. Managers were in the process of identifying specialist staff training for restraint, appropriate for children and young people.

  • Care records were comprehensive, person centred, recovery focused and up to date. Care records showed that a physical examination had been undertaken and that there was ongoing monitoring of physical health problems.

  • Staff were knowledgeable about how both Mental Health Act and Mental Capacity Act applied or not, to the young people they worked with. Staff sought appropriate consent from patients, for example, Gillick competency for examinations and treatment. Staff had explained rights to patients detained under the Mental Health Act and repeated these atregular intervals. Consent practices and records were actively monitored and reviewed to improve how patients were involved in making decisions about their care and treatment.

  • We observed excellent staff handover within the team shift to shift. The service used a structured handover system, which ensured staff communicated all aspects of patient’s care and treatment between shifts. We observed a formulation meeting, and effective multidisciplinary team planning for one patient.

  • The service provided a wide range of age appropriate health promotion information in the welcome pack and in the reception area. Staff assessed patient’s nutrition and hydration needs when they came to the Dragonfly unit. A dietician provided specialist advice.

  • Staff were appraised and supervised and had access to regular team meetings. Staff were experienced and qualified and received specialist training in children and young people. The continuing development of staff skills, competence and knowledge was integral to ensuring high quality care.

  • Each patient had a named nurse and associated worker who offered regular and ad hoc sessions.

  • Staff provided patients with an information pack and verbal information about the unit in a way they could understand.

  • Patients gave feedback about the service. Some patients had contributed to a design mood board with ideas for decorating a communal room and had made soft furnishings.

  • Patients were involved in staff recruitment.

  • We saw sensitive handling of difficult issues. Staff understood the individual needs of patients. We saw staff show exceptional care and respect for a patient who was distressed.

  • Staff recognised and respected the need to empower families to look after their children. Staff reflected individual needs in the delivery of patient care. There was a strong visible person centred culture from all staff.

  • All staff showed encouraging, sensitive and supportive attitude to patients and those close to them.

  • Patient’s emotional and social needs were highly valued by staff at all levels and were embedded in their car and treatment.

  • Feedback from patients and those close to them was continually positive. One patient said this was the best child and adolescent unit they had been to. A parent described the service as resilient, safe and secure for their relative.

  • The service provided structured and individualised therapeutic programmes, comprising of a mixture of group work, activities, exercise, individual sessions and education.

  • Patients were provided with education services and educational materials required for continuing their education.

  • Patients had opportunities for regular exercise for example Friday exercise class, cycling, dance classes, walks on the beach, yoga, and gardening.

  • The trust employed staff to prepare freshly cooked meals on site. There was a choice of food to meet dietary requirements. The service bought fresh fruit and vegetables from local farms, meat from local butchers and some patients grew their own lettuce and tomatoes.

  • Patients had access to a multi-faith room and regular spiritual support. Patients on the ward had created the designs on the walls and decorated the space themselves.

  • Staff told us there was strong leadership, and staff were well supported.

  • The team leader had visited other child and adolescent units and brought ideas back as well as sharing their successes.

  • There was sufficient staff to provide care and treatment to patients.

  • The unit provided for patients and staff a, “What stuck with you this week” board. This was a way for patients and staff to communicate things that had, had an impression on them that week. This could be anything from one of the patient’s doing a Zumba class for the first time, down to a fun meal.
  • Staff participated in regular clinical audits. This included audits such as care programme approach, Mental Health Act and anti-psychotic medicines.

  • There were good opportunities for leadership development.

  • The service was working towards the Quality Network for Inpatient CAMHS (QNIC).

10 July 2017 - 20 July 2017 and 28 July2017

During an inspection of Forensic inpatient or secure wards

We rated the forensic inpatient/secure wards as good because:

  • Staff completed a risk assessment of every patient on admission and updated this regularly and after every incident. Managers had a clear oversight of incidents that had taken place on their wards and ensured that staff learnt from incidents and complaints by discussing them in monthly team meetings and governance meetings with senior managers

  • Staff completed comprehensive and timely assessments when patients were admitted to the wards. Staff involved patients in the writing of their care plans and the staff fully documented patient’s views.

  • Weekly multi-disciplinary meetings took place to discuss patient care and treatment; staff and patients attended this.

  • Care records showed physical examinations were undertaken and ongoing monitoring of physical health took place.

  • The seclusion rooms on Earlham ward and Foxhall house met the required standard as set out in the Code of Practise. Staff fully documentation all episodes of seclusion in the case records.

  • Staff interacted with patients in a caring and respectful manner. We observed staff throughout the inspection engaging patients in meaningful activities and responding to patients needs in a discreet and respectful manner. Staff took time to listen to patients so they fully understood what support the patient required.

  • The majority of the patients we spoke reported they felt safe on the wards. They said staff were kind and caring and took time to support them when needed by either talking or doing activities.

  • Staff demonstrated the values of the trust when they talked about their work and caring for patients. Clinical team leaders ensured that their team objectives reflected the trust organisation’s values and objectives.

  • The provider used key performance indicators to gauge the performance of the team. These were presented in an accessible format and discussed with staff in order to improve on them.

  • Staff we spoke with reported that morale was high with their teams and felt that levels of job satisfaction were high. Staff reported that they felt listened to by their teams and were never afraid to raise issues, as the team or managers addressed them.

However:

  • Ligature audits recorded what actions were required to reduce the risk for patients. However, there were no set timeframes for the work to be carried out to protect patients from the risk of ligatures. This issue had been identified at the last inspection in July 2016 and had not been addressed.

  • The seclusion room on Yare Ward was not in use due to damage. In the interim, the ward had a temporary seclusion room, a converted bedroom. This temporary room did not meet the required standard set out in the Code of Practice. Whitlingham ward seclusion room was not in use at the time of the inspection due to a flood.

  • Staff did not address issues with temperatures in the clinic room on Thorpe ward. Hot temperatures in clinic rooms can affect the efficacy of medication. This issue was highlighted in the 2016 inspection.

  • The shower room in Yare ward had a broken extractor fan and mould on the walls and ceilings. Staff had reported this to maintenance but no action had been taken.

  • Whilst ward managers were able to adjust the staffing levels daily to take into account patient need by requesting additional staff they were not always achieved for unplanned activities, for example admission to the general hospital or seclusion. This resulted in levels of staff on the ward being reduced and cancelled sessions and cancelled section 17 leave.

  • Managers did not ensure that staff completed a compliance level for all mandatory training of above 75%. Managers did not complete staffs annual appraisals.

10 July - 20 July, and 26 July 2017

During an inspection of Long stay or rehabilitation mental health wards for working age adults

We rated long stay/rehabilitation mental health wards for working age as requires improvement because:

  • There was a ligature risk audit in place but no date recorded for the completion of outstanding actions to mitigate risk.

  • There was access to personal alarms but no nurse call systems. We observed that staff at St Catherine’s did not use the alarms and there was no system in place for signing alarms in and out.

  • Staff vacancies and turnover were high and between 1 April 2016 and 31 March 2017 the service had used bank or agency staff to cover 40% of shifts. Four per cent of nursing assistant shifts had not been filled. There was not always a qualified nurse on duty at St Catherine’s.

  • Not all care plans reviewed reflected the patient involvement.

  • We reviewed five out of seven medication charts at Suffolk Rehabilitation and Recovery Service. There were discrepancies in three of the consent to treatment forms that we looked at. One included physical health medication in additional to mental health, one was not correctly updated and the frequency of the dosage was incorrect in another.

  • The trust were unable to provide the clinical supervision data for non-medical staff for the period 1 April 2016 to 31 March 2017. Ward managers found it difficult to access supervision data electronically.

  • As of March 2017, the overall appraisal rate for non-medical staff was 46%. The trust target was 89%, all wards within this core service failed to meet this target. The highest appraisal rate was Suffolk rehabilitation and recovery service with 52% of staff having had an appraisal. St Catherine’s appraisal rate was 33%. As of March 2017, the trust had provided data that suggested that no permanent medical staff required or have had an appraisal in this core service.

  • There were 19 readmissions within 28 days of discharge out of a total of 149 patients discharged, as reported by the service from 1 April 2016 to 31 March 2017. On average patients were being readmitted to long stay/rehabilitation wards within 11.8 days of being discharged. Follow up care and treatment was provided by the crisis home treatment team. Staff also highlighted that some patients discharged themselves.

  • Ward systems were not always effective in ensuring that patient and staff safety was maintained.

  • The electronic system did not support managers in ensuring that supervisions and appraisals were up to date.

  • Shifts were not always covered by a sufficient number of staff of the right grades and experience. Bank and agency staff were often used to provide cover for sickness and absence.

However:

  • Staff undertook a detailed risk assessment of every patient on admission and updated this regularly and after every incident. This was evidenced at both wards and in all 13 of the patient care records that we reviewed.

  • Care records showed that a physical examination had been undertaken and that there was ongoing monitoring of physical health problems.

  • Patients at both wards told us that staff were cheerful, caring and supportive. They said that staff were always available and helpful with their needs.

  • There was a carer’s protocol, carers’ information pack and a carers’ champion on each of the long stay/rehabilitation mental health wards for working aged adults. When a patient is admitted, carers were offered a 1:1 carers forum meeting as part of the overall planning process for the patient

  • There was access to a range of activities during the week and at weekends. There was a detailed timetable of activities on the noticeboard and patients told us that they engaged in activities both on the ward and in the community, including trips home to promote independent living.

  • Mandatory training was above trust compliance rates.

10 to 20 July, 25, 26 and 28 July 2017

During a routine inspection

This report describes our judgement of the quality of care provided by Norfolk and Suffolk NHS Foundation Trust. Where relevant we provide detail of each core service, location or area of service visited.

We rated Norfolk and Suffolk NHS Foundation Trust as inadequate overall because:

  • The board had failed to address all the serious concerns that had been reported to them since 2014. The breaches of regulation identified at our previous inspections had not been resolved. The board did not ensure that the services provided by the trust were safe. They had not taken action to ensure that unsafe environments were made safe and promoted the dignity of patients. They had not ensured that there were sufficient staff to meet patients’ needs safely. They had not ensured that unsafe seclusion and restrictive practices were minimised or eradicated. The trust was not safe, effective or responsive at all services. The board needed to take further and more timely action to address areas of improvement.
  • We had a lack of confidence that the trust was collecting and using data about performance to assure itself that quality and safety were satisfactory. The direction of travel could not be determined due to the contradictory nature of the data. Information was not always robust. The board needed to ensure that their decisions were implemented and brought about positive improvement.
  • Performance improvement tools and governance structures had not facilitated effective learning or brought about improvement to practices in all areas.
  • Key mandatory training was below acceptable levels. Many staff had not received regular supervision and appraisal.
  • A lack of availability of beds meant that people did not always receive the right care at the right time and sometimes people had been moved, discharged early or managed within an inappropriate service.
  • Community and crisis teams’ targets for urgent and routine assessments following referral were not always being met in all areas.
  • The poor performance of the single electronic records system had a negative impact had on staff and patient care.
  • There were errors in the application of the Deprivation of Liberty Safeguards and the Mental Health Act.

However:

  • Morale was found to be good across the trust. This was supported by the staff survey and the staff element of the Friends and Family Test.
  • We observed some positive examples of staff providing emotional support to people.

On the basis of this report we are recommending that the trust is placed into special measures.

10-20 July 2017

During an inspection of Wards for older people with mental health problems

We rated wards for older people with mental health problems as requires improvement because :

  • Staff had made Deprivation of Liberty Safeguards applications for a number of patients across all wards. On patient records checked, all but two had not been authorised by the local authority. On six wards, the urgent authorisation had expired and there was no evidence that staff had applied for an extension. One patient on Abbeygate had been secluded twice without a Deprivation of Liberty Safeguards authorisation in place.
  • There were staff shortages across most wards. We saw evidence that wards often ran below established qualified staffing levels. One ward had run at less than half the required qualified staff at night, on average, from January 2017 to March 2017. The service had high vacancy rates and used a high number of bank and agency staff to cover shifts. There had been six reported incidents where there were not enough trained staff to provide patients with the physical interventions required to keep them and others safe. The service medical input was below the established level. This meant that consultants did not review patients as often as needed.
  • On Willows, there were a number of medicines management issues. These included medicines being out of date, for example eye drops and skin treatments. There were a number of creams opened that staff had not labelled with individual patient details. Staff had not labelled liquid medicines with the date opened on Willows and Abbeygate.
  • The seclusion room on Abbeygate did not comply with the Mental Health Act code of practice. The bathroom was located in the low stimulus area outside the seclusion room, there was no staff observation area and the room was located on the main corridor of the ward. Staff had not completed seclusion records for one patient in line with the trust policy. Observations had not been recorded, there was no seclusion care plan for one episode and the name of the practitioner who authorised the second seclusion had not been recorded.

However:

  • The environment on wards was clean and safe. Managers had completed up to date ligature audits and risk management plans with mitigation in place and known by staff. Staff ensured equipment was maintained and checks were up to date.
  • Risk assessments for patients were detailed and up to date for all patient records reviewed.
  • The team used a range of assessments and outcome measurements to support patients.
  • There were full and well organised multidisciplinary teams on six of the eight wards.
  • The atmosphere on the wards was calm and we observed positive interactions between staff and patients.
  • There was a full range of rooms and spaces to provide therapy and care to patients. The service provided a range of activities.
  • Staff felt supported by their managers and were able to raise concerns if necessary.

30 May 2017

During an inspection of Wards for older people with mental health problems

As this was a focussed inspection to one ward, in response to the concerns identified by a member of the public, we did not rate this core service.

However, the trust needs to address the following areas of concern:

  • There was no dedicated ward manager for this ward. This post was shared with an adjacent ward. We found a lack of direction on the ward.

  • There was no formal system to ensure that each individual patient’s welfare was checked and reviewed at regular intervals throughout the day. Individual care plans were in place but these had not been updated in some cases to reflect increased risks to patients and staff.

  • Some care records reviewed included incorrect or contradictory information. For example relating to the physical healthcare needs of patients.

  • There was no current dependency tool used to establish staffing levels. We found that adequate numbers of staff were not deployed to meet the needs of the patients on this ward.

  • The ward layout did not protect patient’s privacy, dignity and safety to meet the Department of Health guidance in relation to the arrangements for eliminating mixed sex. We found that one female patient had to use the communal bathroom as her en-suite facility was out of order. This had been reported by front line staff but was awaiting repair.

  • Staff reported problems with en-suite showers. Some were not working properly. Frontline staff confirmed that these issues had been reported to the trust’s maintenance department. However, these maintenance concerns had not been addressed.

  • Concerns identified by us during this inspection had not been identified or addressed by the trust’s own governance processes. There was no coherent and consistent ward based response when local concerns and complaints were raised.

  • Staff morale was low and some staff said that middle managers ignored their concerns.

However:

  • Frontline staff were working hard to deliver care and support to patients, who often presented with behaviours that could be challenging, without effective direction from senior staff.

  • Medication records were well kept and we noted the low level of use of antipsychotic medication. Documentation for the administration of covert medicines was up to date.

12 July 2016 – 22 July 2016

During an inspection of Mental health crisis services and health-based places of safety

We rated crisis services and health based places of safety as requires improvement overall because:

  • Staff in Crisis resolution home treatment (CRHT) teams in Norfolk managed high volumes of referrals 24 hours a day. In three CRHT teams, caseloads exceeded the recommended number of 30 patients.
  • The trust provided data that showed four patients from CRHT Hellesdon had delayed discharges as they were waiting allocation to a care co-ordinator in the community team. The trust did not consistently monitor delayed discharge information across all services.
  • The psychiatric liaison services environments were not fit for purpose for assessing patients experiencing a mental health crisis.
  • The CRHT teams had variable access to personal alarms when on duty.
  • Staffing of the health-based place of safety (HBPoS) suites was managed in different ways across the trust. Specifically allocated staff managed some units and staff from acute wards staffed other suites when a patient was admitted. This reduced the staffing numbers on the acute service when they were needed to staff an admission to the suite.
  • HBPoS at Northgate did not have risk assessments documented. Staff had not completed risk assessments in all 19 care records we reviewed.
  • The environment in health-based places of safety was unsafe. Furniture was not fixed to the floor, it was light and could be thrown or picked up by patients. The rooms were not clean and the ligature environment risk assessment did not identify risks we found.
  • Medication was not stored, managed or transported as required by best practice in two CRHT teams.
  • Staff were not receiving clinical and managerial supervision regularly across the core service.
  • Appraisal rates for staff did not meet the trust compliance target.
  • Staff mandatory training did not meet the trust compliance target.
  • The reading of Mental Health Act rights to patients was poor at the HBPoS suite in Northgate hospital. Only six out of 19 patients who had used the suite had been read their rights, and had been recorded in the patient record.
  • Staff had not completed or recorded physical healthcare checks for patients in all 19 care records reviewed at Northgate HBPoS.
  • Members of the public did not know crisis telephone numbers. Staff re-directed the crisis calls to the acute ward at night in one service when staff from the crisis team were out of the office.
  • The trust had no single service wide operational policy guidance for staff on how to meet targets for emergency (four hour), urgent (72 hour) or routine (28 day) referrals.
  • Staff told us there were significant delays in an approved mental health professional (AMHP) attending HBPoS out of hours.
  • There is no single service wide policy for crisis services from the trust. All localities managed their services using a local model.

However:

  • We saw good evidence of lone working practices and the systems in place to manage this.
  • CRHT at Northgate had a clean, alarmed unit.
  • CRHT and home treatment teams (HTT) held effective team meetings.
  • Care plans across the services were detailed, up to date and person centred.
  • Staff recorded patient involvement in care plans.
  • Staff we spoke with showed commitment to and passion for their job. We saw face-to-face interactions and telephone conversations with patients where staff showed compassion, empathy and knew their patients well.
  • We observed team meetings that were patient centred. Discussions considered the involvement of carers and families.
  • Staff told us they felt supported by their managers and felt managers were visible in the services. We observed core team leaders being supportive of their staff.

12 - 22 July 2016

During an inspection of Specialist community mental health services for children and young people

We rated the community mental health services for children and adolescents as ‘requires improvement’ overall because:

  • If staff could not contact a patient requiring urgent assessment within 72 hours, they sent an ‘opt in’ letter out. The letter requested that the referred person make contact with the service within 14 days. If there was no contact, staff referred the person back to the original referrer and potentially discharged them.

  • Waiting times from referral to assessment varied across the teams visited. Not all teams were meeting targets.

  • We found that some staff had an unacceptable number of patients on their caseload.

  • Staff were not up to date with mandatory training, including the Mental Health Act and Mental Capacity Act.

  • Waiting times for allocation of a care co-ordinator could be several months in some instances.

  • Core assessment and risk assessments were not completed in a timely manner following the first face to face assessment.

  • Waiting times for psychological therapies ranged from three to eight months.

  • There was not a standard physical health screening tool used across the service.

  • Staff did not receive regular clinical supervision or annual appraisals.

  • Patients were not involved in their care plans. Not all patients had care plans.

  • There was limited flexibility in staff offering appointments outside of office hours.

  • We found that staff could not navigate the electronic record system properly which resulted in delays with locating information.

  • We saw significant gaps in patient records. Staff felt this was due to the change-over of the electronic records system.

  • There were no systems for monitoring whether the risk levels of patients referred had changed.

  • There were no systems to monitor whether targets were being met or actions taken if targets were not met

However:

  • There was adequate medical cover throughout the 24 hour period. The trust had an on call rota system whereby a children and young people’s consultant could be contacted.
  • Staff knew how to report incidents, and there was feedback about significant events within the trust.
  • Staff understood the process of making a safeguarding referral and had established links with local teams.
  • There was a good range of skilled staff across the teams to deliver care and treatment.
  • Crisis teams were able to respond to patients quickly.
  • Clients and families contacted told us that staff were kind and respectful.
  • We saw a variety of information around care and treatment for patients and families. Staff sign-posted patients to other organisations appropriately.
  • Some services had recently developed weekly drop-in clinics that enabled staff to see patientson the waiting lists if they self-presented.
  • Staff were aware of the vision and values of the trust and had discussed these in local team meetings.

12 - 22 July 2016

During an inspection of Community-based mental health services for older people

We rated community-based mental health services for older people as requires improvement overall because:

  • Risk assessments and care plans were not always in place and person centred. These were sometimes difficult to find on the electronic record system. People who used the service were not always given copies of their care plans.

  • There was concern that high caseloads could compromise patient safety. Managers told us there were no waiting lists for routine assessments however five of the CLL teams failed to meet the 28 day target.

  • There was a waiting list at Ipswich Coastal IDT for people to see a psychiatrist for routine appointments and clinics had to be cancelled due to insufficient numbers of doctors. This meant morale in this team was lower than elsewhere in the service. There were also difficulties accessing medical input in the Suffolk DISTs.

  • The use of the Mental Capacity Act was not being consistently documented or considered for people who were thought to lack capacity across all the teams in the service.

  • In Norfolk and Waveney, the dementia intensive support team provided emergency and crisis support till 9pm (8pm in Kings Lynn). Suffolk intensive support services did not provide out of hours crisis support; services closed at 5pm. People in crisis sought support from out of hours GP services, ‘111’, ‘999’ or the local authority emergency duty team.

  • Some of the clinic and interview rooms did not promote privacy and confidentiality.

  • Not all staff felt the teams were supported when requesting additional resources.

However:

  • Across the service, 85% of staff had completed mandatory training; 96% of staff had completed Mental Health Act training and 96% had completed Mental Capacity Act training.

  • Safeguarding training in most teams was between 95% and 100%, and staff knew how to identify abuse and make a safeguarding referral.

  • Staff said they felt supported by their managers who provided effective leadership to the teams.

  • Emergency and urgent referrals were responded to within timescales set by the trust.

  • Staff responded quickly when people became unwell and arranged to see people in their own homes at a time convenient to them.

  • Managers felt they could approach senior managers within the trust and said they came to visit the teams.

12 to 22 July 2016

During an inspection of Wards for people with a learning disability or autism

We gave an overall rating for wards for people with learning disabilities or autism requires improvement because:

  • The trust had not ensured standards of care were maintained pending the closure of this service.

  • Although staff at Walker Close had a plan to reduce the number of fixtures on the ward that could be used by patients to tie a ligature to, the plans did not provide sufficient detail or action to mitigate the risks.

  • At Walker Close the documentation for the administration of covert medicines for two patients w not up to date. The temperature in the rooms containing medication in the two bungalows had repeated readings above 25 degrees which may affect the efficiency of the medication.

  • The ward setting was basic and poorly maintained at Walker Close. The chemical products cupboard lock was broken, and washing tablets were left out. Large weighing scales were stored in the communal lounge against the wall. This presented safety risks to patients.

  • There was a high use of bank and agency staff at Walker Close, particularly at weekends which impacted on patient care.

  • At Walker Close care plans lacked detail and were not always personalised. Electronic care records were muddled and hard to follow. It was not possible to find the care plan for one patient. This meant staff were not able to easily identify or adequately maintain up to date records and this impacted on patient care.

  • Some physical health care checks were not recorded in the patient’s care plan although these were completed weekly as part of the ward culture at Walker Close. Patient’s risk assessments for fluids and nutrition lacked detail.

  • There was a shortfall of clinical staff including psychologists, psychiatrists and occupational therapists to meet patients’ treatment plans at Walker Close.

  • Staff did not attach importance to regular appraisals saying that the unit was closing..

  • At Walker Close the setting did not promote people’s dignity with continence pads on display in patients’ bedrooms, and patients’ personal care products stored together in the communal bathroom.

  • We observed one patient left in the same chair in an undignified position most of the day at Walker Close. The patient was able to move independently but was unwell at the time of our visit.

  • There was no clear evidence of discharge plans or care and treatment reviews at Walker Close.

  • Patients were able to personalise their bedrooms. However we saw bedrooms at Walker Close were not personalised. This was the responsibility of staff on wards, together with the individual patient. The lack of personalisation of bedrooms was a feature throughout the bungalows.

  • At Walker Close patients had limited access to activities to promote their treatment and recovery.

  • We observed that some staff were disaffected. Staff told us they did not know senior managers in the organisation as those managers had not visited the wards, but we were shown evidence of a number of board level visits and meetings with staff to discuss the changes as well as a thorough consultation process.

  • There was a limited approach to obtaining the views of people who use the services and other stakeholders including carers.

However:

  • At 7 Airey Close the ward layout was good and allowed staff to observe all parts of the ward. All ward areas were clean and well maintained. Staff had access to appropriate alarm systems between wards. A colour coding system for medicines storage through to care plans was in place that helped staff coordinate patient care and reduced the risk of errors. There were sufficient staffing levels.

  • At Walker Close moving and handling risk assessments were in place and linked to the prevention and management of aggression, were clear and specific. Patients had a health passport and My Plan (a person centred plan) that included information about how the patient wanted their care to be delivered. There was evidence of medical examinations having taken place. Where patients had physical health needs identified they had an initial assessment and this was followed up with access to specialists.

  • At 7 Airey Close care plans were comprehensive and treatment was based on National Institute for Health and Care Excellence (NICE) guidelines. There were behaviour support plans in place.

  • At both locations we observed effective handovers within the team from shift to shift. Staff received mandatory training and regular supervision.

  • There was access to advocacy services at both sites.

  • At Walker Close we observed one staff member as particularly positive, thoughtful and caring. The same staff member was concerned about the high weather temperatures and impact on patient care. Staff ensured extra drinks were provided. At 7 Airey Close staff talked positively and compassionately about patient care. The weekly multidisciplinary meetings included the patient and carers.

  • At 7 Airey Close activities were available seven days a week. Staff had the use of two ust vehicles to facilitate this. Fresh food was prepared and cooked for patients on site.

  • Staff at 7 Airey Close told us they felt well supported by the ward manager.

12 July 2016 to 22 July 2016

During an inspection of Community-based mental health services for adults of working age

We gave an overall rating for community based mental health teams for adults of working age as requires improvement because:

  • Staff lacked confidence in the trust’s electronic recording system and described it as difficult to use. We saw that most staff struggled to access or input patient information easily.

  • Teams operated differently across the trust. These differences made the referral pathway potentially difficult to understand for patients, staff and healthcare professionals.

  • There were nursing vacancies in every team. Two teams had vacancies for consultant psychiatrists. This interfered with the quality and continuity of care offered to patients. There were differences in how teams were made up across Norfolk and Suffolk. This meant that there were inconsistencies in service provision offered to patients. There was not a standardised caseload allocation tool throughout the core service.

  • Clinic rooms in Bury North, Great Yarmouth East Coast Recovery team and West Norfolk ACMHS were in need of improvement. We found that the trust had not taken action to address recorded temperatures over 25 degrees in the majority of clinic rooms. Evidence of annual checks and re-calibration of medical equipment was not available at Bury North and Bury South.

  • We found that documentation relating to care programme approach (CPA) review was lacking in some patient records. This meant that we could not be certain that all patients had received a full formal CPA Review as required.

  • Staff had not identified areas for improvement and addressed concerns following internal medicine management audits that were carried out. Staff had not completed some medication records in full. We found that the Mental Health Act CTO forms were not always kept with the medication record.

  • Some staff across the teams told us they felt they could not raise their concerns without fear of victimisation. The majority of staff spoken with felt that the pace of change within the trust was difficult to manage.

However:

  • Assessment and focussed intervention or access and assessment staff completed initial risk assessments and triaged patients to the relevant teams efficiently. Physical healthcare needs were considered. Staff described how they risk assessed and tried to engage with people when they did not attend appointments. The teams worked to a lone working practice protocol.

  • There was a small waiting list for treatment in most areas.

  • Staff had annual appraisals. Regular clinical and managerial supervision was taking place. Staff were mostly up to date with mandatory training and knew how to make a safeguarding referral.

  • Learning from incidents was disseminated across teams and the wider trust through a variety of routes that included electronic and face to face learning.

  • Staff were respectful and caring when they spoke with patients. Patients said they were involved in their care planning and treatment. Senior staff were aware of the ‘Duty of Candour’ requirement. Staff helped patients to make complaints and signposted service users to advocacy services when needed.

  • Staff said morale had improved since the trust had re-organised services and improved leadership and accountability.

12 - 22 July 2016

During an inspection of Community mental health services with learning disabilities or autism

Overall we rated community mental health services for people with learning disabilities and autism as ‘requires improvement’ because:

  • Leadership across this core service was disjointed. Effective governance systems were not in place as consistent key performance indicators were not used by the trust to monitor performance across all teams. A uniform process for managing caseloads and identifying changes in risk or need for patients held on waiting lists was not in place across different teams.

  • Some patients had long waits to access some specialist services such as speech and language therapy and psychology.

  • Appropriate staffing levels had not been maintained within some teams, for example Adults Learning Disability Service Great Yarmouth and Waveney and Learning Disability Service (CAMHS) Waveney teams.

  • Patients placed on waiting lists at Adults Learning Disability Service Great Yarmouth and Waveney were not regularly reviewed to ensure that changes in risk and need were identified and responded to.

  • At Adult Learning Disability Service Great Yarmouth and Waveney, robust procedures relating to lone working when visiting patients at home were not in place.

  • Some staff were not confident in carrying out decision specific mental capacity assessments where they identified this need and deferred to psychologists or psychiatrists within the teams to undertake these assessments.

  • A minority of care plans were not person centred or holistic. Leaflets were not widely available at the adult and CAMHS community teams in easy read formats or in languages other than English.

  • Systems to establish and maintain effective working relationships with all GPs within geographical teams had not been developed. Staff morale had been impacted by prolonged service reconfiguration discussions. Some staff did not feel listened to or consulted with by the senior management team in relation to proposed service changes.

However:

  • Services were provided in safe, clean environments that were appropriately maintained. Staff had manageable caseloads. There was rapid access to a consultant psychiatrist when required and there was good joint working with primary and social care services to meet individual patient needs.

  • Staff were experienced and skilled; they received regular supervision, were appraised and attended regular team meetings. Staff were mostly up to date with mandatory training; where this had expired refresher training had been booked. Staff were trained in and had a good understanding of the Mental Health Act. Within (CAMHS) teams staff were aware of and considered Gillick competency when considering mental capacity issues for children and young people. Patients were given appropriate support and assistance to make decisions for themselves before they were assumed to lack capacity. Staff were responsive and respectful when interacting with patients and carers and understood patient and carer needs.

  • Comprehensive initial and risk assessments were completed at initial assessment and regularly reviewed and updated. Where required, detailed behaviour support plans had been developed in collaboration with patients and their carers. Patients physical healthcare needs were assessed and addressed. Patients and carers gave very positive feedback of their experience with staff. Patients and carers knew how to complain and received feedback.

  • Staff followed NICE guidance when prescribing medicines and a full range of psychological therapies were available. Urgent referrals were seen quickly and non urgent referrals within two to four weeks. Staff were able to submit items to the trust risk register and knew how to whistleblow. All incidents that should be reported were reported and staff received feedback on the investigation of incidents.

12 July 2016 - 22 July 2016

During an inspection of Long stay or rehabilitation mental health wards for working age adults

We rated Suffolk Rehabilitation and Recovery Service as good overall because:

  • The ward complied with the Department of Health guidelines on single sex accommodation.
  • Managers completed ligature risk assessments, which were comprehensive and highlighted the risk areas; the ward had mitigated risk and promoted observation by installing CCTV in all day areas and corridors.
  • The ward had a new response alarm system in place.
  • There were no episodes of restraint within the last six months.
  • There was a system in place for tracking and learning from safeguarding incidents and other reportable events.
  • The managers used an acuity tool to identify and review staff numbers in accordance with need.
  • Staff completed detailed risk assessments for most patients on admission and reviewed them regularly.
  • We saw evidence of patient involvement in care plans; the plans were recovery-orientated and discharge planning was in place.
  • We found staff to be caring and responsive to patients.

However:

  • Staff did not follow the National Institute for Health and Care Excellence (NICE) guidance for patients on high dose antipsychotic medication.
  • Doctors did not ensure that consent to treatment forms were adhered to when prescribing medication.
  • Not all staff were not up to date with mandatory training.
  • Managers did not ensure that all staff had keys to access all areas of the service.
  • Staff did not record that they had monitored patients’ physical health care.
  • Only 44% of staff had received supervision in the previous 5 months.
  • The ward was frequently unable to fill the second qualified staff member on night shift.

12 - 22 July 2016

During an inspection of Child and adolescent mental health wards

We rated the ward for children and adolescents with mental health problems as good overall because:

  • Staff assessed and reported any safeguarding concerns in order to protect young people from harm.

  • Staff updated the risk assessments of young people following incidents. Debriefs were held where possible following incidents on the ward. This enabled staff reflection and learning.

  • We saw that professionals worked together to ensure that they met the needs of young people who used the service.

  • Staff provided care and treatment that was informed by national evidence and research.

  • Young people were encouraged to make choices and decisions about their care and treatment.

  • Staff had effective communications with families and carers with appropriate involvement encouraged.

  • The ward offered a wide range of information and leaflets around health promotion, how to complain and the rights of being an inpatient, whether informal or detained.

  • Young people were supported through their care pathway. There was evidence of active discharge planning.

  • The ward offered a structured therapeutic programme, which consisted of leisure activities, therapeutic activities and educational sessions.

  • Young people knew how to give feedback about the service and how to complain. There were systems for reviewing complaints in order to improve the service.

  • Staff were able to give feedback on the service and also input into future service development.

However:

  • There had been use of physical restraint which resulted in young people being in the prone (face down) position. However, there were practices in place to minimise the length of time and to de-escalate situations where this might be used.

  • There were some areas where ligatures could be tied, but staff had mitigated these risks as much as possible.

  • Not all vacant shifts had been filled with bank or agency staff. This meant that the ward had to work below usual numbers on occasions.

  • Staff across young person services in the trust reported a lack of inpatient beds for young people during crisis. This meant that on occasions young people were admitted to a hospital a long way from their home.

12 July 2016 - 22 July 2016

During an inspection of Forensic inpatient or secure wards

We rated the forensic services as good overall because:

  • Staff completed detailed risk assessments for every patient on admission and reviewed these regularly.
  • The service had good medicine management systems in place.
  • Staff completed comprehensive care plans that were personalised, holistic and recovery orientated for all patients.
  • Care records showed that physical examinations had been undertaken and there was ongoing monitoring of physical health problems for patients.
  • The majority of patients told us they felt safe on the wards and staff were kind and supportive of them.
  • Patients were actively involved in the writing of their care plans and risk assessments, and attended weekly ward rounds and care programme approach meetings.
  • Managers ensured that they shared the outcomes of investigations and complaints in team meetings.
  • Managers had access to key performance indicators to gauge team performance and compare against other wards within the service.
  • Staff reported that team morale was good and they felt support by all members of the team.

However:

  • Seclusion rooms at the Norvic Clinic and Hellesdon Hospital did not meet the required standard as set out by the Code of Practice. Although, the trust had a refurbishment plan in place to improve the seclusion facilities at the Norvic Clinic, which will begin in August 2016.
  • Staff had not completed seclusion records as per trust policy and they could not locate all seclusion records. Some seclusion records were on case notes however, staff had not completed them fully. We found evidence within the notes that staff offered patients urine bowls instead of using the toilet facilities adjacent to the seclusion room.
  • Staff used prone restraint in 47 out of 130 restraint incidents.
  • Senior managers did not ensure that they had the required number of nurses for all shifts at Foxhall House and Acle ward.
  • Managers completed ligature and environmental risk assessments, but no action had been carried out to minimise assessed risks to patients.
  • Not all staff received regular supervision.
  • Patient’s records were difficult for staff to navigate to find important patient information easily.

12 to 22 July 2016

During an inspection of Wards for older people with mental health problems

We rated wards for older people with mental health problems as requires improvement overall because :

  • Trust governance systems were not fully effective in identifying and responding to risks. Examples of risks for this service related to mixed sex accommodation, medicines management, records access, staffing, training and support.

  • Most ward layouts did not always protect patient’s privacy, dignity and safety to meet the Department of Health guidance and Mental Health Act 1983 code of practice in relation to the arrangements for eliminating mixed sex. We found examples where this could pose a risk to patients, for example, on Abbeygate ward we saw a woman walk into male area without staff intervening.

  • Ligature assessments did not always detail risks on the wards and in gardens, for example at Beach, Rose, Reed and Sandringham wards.

  • Some equipment checks including emergency response bags were not consistent.

  • Abbeygate staff did not always complete physical health observations of patients following rapid tranquilisation.

  • We found some issues relating to medication ordering, record keeping and use of covert medication, for example on Abbeygate and The Willows wards.

  • Across wards staff reported challenges with requesting additional staff. Trust information showed staffing shortfalls. Some wards did not have easy access to a ward doctor.

  • Staff across sites were not receiving clinical supervision, appraisals and training regularly.

  • Staff across all sites reported challenges with recording information and finding information using the electronic patient record.

  • Records did not always capture patients and carers involvement in care planning.

  • The trust did not have clear information available on how deprivation of liberty safeguards (DoLS) authorisations across the service were monitored and how information was being communicated to ward staff about their role and legal responsibilities regarding giving patients care and treatment.

  • Consent to treatment and Mental Capacity Act 2005 (MCA) assessments were not always available in patients’ records and detail varied across the service including for do not resuscitate assessment and recording.

  • Fernwood, Foxglove and The Willows wards did not have easy access to a speech and language therapist which meant specialist assessments were delayed.

  • There were waiting lists for admission to wards especially for Norfolk and some patients were being placed out of area. Some community teams said it was difficult to get patients admitted to hospital when needed. Overall the trust’s bed numbers had decreased.

  • Staff reported challenges with discharging patients due to a lack of community placements and funding arrangements beyond their control.

However

  • Staff gave us examples of learning from incidents after they had been reported, to reduce future risks.

  • We found staff carrying out infection control checks and responsive cleaning to keep areas clean.

  • Block booking of agency and bank staff were made on most wards to ensure regular staff delivered care.

  • Staff completed comprehensive and detailed risk assessments.

  • We found examples of good physical health care and staff accessing specialist services for example at Abbeygate ward.

  • General nurses were employed to assess and care for patients physical health needs.

  • Staff told us there was more focus on supporting patients in the community, meaning there was less pressure on beds. Beach ward had reduced its length of stay for patients.

  • Facilities promoted recovery and comfort, for example there were spacious areas and signage and pictures had been developed to assist patients to orientate themselves. Wards were suitable for patients with mobility difficulties.

  • Patients and carers said staff were kind and caring and treated them with dignity and respect.

  • Carers were encouraged to give feedback on the service and support groups were available to help people cope with caring for someone with dementia or mental illness.

  • Managers had access to a range of governance systems to measure their wards performance and identify areas for improvement.

  • Staff said they were proud of their work, felt supported to deliver care and most said morale had improved.

  • At Julian Hospital and Carlton Court, staff had implemented, ‘safer care pathways, ‘closing the gap in patient safety’ to improve communication and reduce incidents.

12 July to 22 July 2016

During an inspection of Acute wards for adults of working age and psychiatric intensive care units

We rated acute wards for adults of working age and psychiatric intensive care units as requires improvement because:

  • All wards had carried out extensive work in improving the environment and reducing the risk of harm due to ligatures. There were audits on all wards and action plans in place to remove or manage the risk. However, the size and build of Churchill ward makes it very difficult for staff to manage these risks. All of the beds in Churchill Ward were a ligature risk and although staff documented this and there were management plans in place, it was an area of concern, particularly at night. The plans depend on staff high vigilance and it was easy to foresee occasions where staff may be required to respond to other incidents on the ward and not be able to carry out the level of observation required.

  • Staff had not updated some of the ward ligature risk assessments to reflect action taken and some items had been identified for removal for six months without action.

  • Ward gardens had blind spots due to shrubbery and bushes. There was CCTV on the wards but staff did not monitor this at all times. Staff did not always supervise the garden areas.

  • We had concerns that staff used the S136 suite in the Fermoy unit at night for seclusion. There was one set of notes that indicated it was used in this way and the ward manager confirmed that at night she had been aware this had happened on a rare occasion to reduce patients being disturbed during the night. The S136 suite was not an appropriate area to nurse a patient in seclusion. Staff also reported that the S136 suite on Wedgwood was used for seclusion on occasion. We did not see this on inspection.

  • Medication management has improved since the last inspection. However, there were still some key areas that needed addressing. The monitoring of physical health following administration of rapid tranquilisation medication was poor and non-existent at times. Despite internal audit taking place there were still incidents of unacceptable levels of gaps in signature on some medication charts.

  • Staff recorded medication fridge temperatures daily but on two wards no action was taken when the temperature was out of range and one ward did not monitor for a whole month. The trust could not be sure that medicines were stored appropriately to ensure their quality and efficacy.

  • Staff documentation of when ‘as required’ medication was given to patients and its efficacy, was poor. Staff did not record the reason the patient required the medication on several occasions. Not all incidents in continuous notes were recorded on the incident reporting system (Datix), nor added to the risk assessment.

  • The Trust was non-compliant with national controlled drug legislation when ordering controlled drug medication from another trust from Northgate and Southgate wards.

  • There were standardised care plans in place regarding the use of least restrictive practice and staff did not record patient personal views. On Waveney ward, three care plans included a seclusion plan or consideration for transfer to a PICU when this was not clinically indicated. Those care plans were inaccurate.

  • Forty two per cent of all restraints resulted in prone restraint. This remained high although it was a 6% reduction of recorded incidents of prone restraint since the inspection in 2014.

  • Staff completed risk assessments for patients on admission. Staff did not routinely update the risk assessments. The risk assessments were not accurate in many records we reviewed across the wards and did not reflect all the patients’ risks. Staff did not always add incidents that occurred during admission to the risk assessment, and staff did not report all events on the incident reporting system, known as Datix.

  • We noted that staff poorly documented seclusion records and events. The electronic record system did not support seamless records and it was difficult to navigate the system. Staff were unable to find information, and we spent a disproportionate length of time trying to ascertain if the patient received appropriate care. We noted that doctors did not always write entries, there were missing times of when seclusion ended, and staff used terminology such as ‘open’ seclusion. It was not always clear when seclusion became long-term segregation. It was not possible to confirm if staff regularly offered food and fluids to patients during seclusion, as staff did not routinely record this.

  • It was evident that staff did not record all incidents in the continuous notes. We noted staff had not always reported incidents documented in the contemporaneous notes as a Datix incident. This means that the trust did not have a true reflection of incidents on the wards.

  • We saw evidence of some capacity assessment outcomes in the patients’ continuous notes. There was no rationale in continuous records as how the staff reached a decision.

  • Patients on all wards reported that they had experience of staff cancelling Section 17 leave due to staff shortages.

  • Staff supervision was patchy, with some ward staff receiving less than two supervisions in a 6 month period.

However:

  • It was clear that there had been significant efforts made by the trust to address ligature risks on the wards.

  • Clinic rooms were clean and tidy.

  • Medicines were stored securely and staff completed monthly audits for safe storage.

  • Access to medicines was good and medicines for discharge were readily available.

  • The trust provided information routinely regarding serious incident learning. Minutes of meetings demonstrated that staff did share, review and discuss incidents.

  • Staff completed and recorded physical health examinations and assessments on admission.

  • Many wards had access to a physical health nurse to support teams to ensure that staff supported patients to address their physical health needs. Staff monitored physical observations and physical health problems. Staff discussed physical health needs at weekly multi-disciplinary team meetings and physical health needs were considered in care plans.

  • We observed all MHA detention papers were completed correctly, up to date and stored appropriately.

  • Staff informed all patients detained under the Mental Health Act (MHA) of their S132 rights on admission.

  • All Section 17 forms reviewed were up to date.

12 - 22 July 2016

During an inspection of Substance misuse services

We rated substance misuse services as good because:

  • Staff were aware of who the safeguarding leads within NRP and the trust were. Staff had good working relationships with adult social care, children’s social care and the local multi agency safeguarding hub (MASH).
  • Managers fed back learning from incidents and areas of good practice in weekly team meetings.
  • Staff completed holistic and specific assessments, recovery plans and risk assessments with clients at the start of treatment and updated them regularly.
  • Clinical case notes were thorough and detailed, and had up to date details in client records, including prescribing dose and frequency.
  • Staff offered a range of psychosocial therapies recommended by The National Institute for Health and Care Excellence (NICE), available as one to ones or group work.
  • All NRP services offered a blood borne virus (BBV) testing and vaccination programme.
  • Clients told us that staff were interested in their wellbeing and that staff were respectful, polite and compassionate. Clients felt they were treated as an individual.
  • NRP worked with families and carers of clients. Carers could attend groups which provided the opportunity for mutual support.
  • Managers supervised staff regularly.
  • Staff and managers said morale was high and they felt valued and rewarded. Staff spoke with passion about working with the client group.
  • NRP facilitated a pregnancy liaison partnership protocol for pregnant clients across Norfolk to ensure that any pregnant clients received additional support.

However:

  • Staff at Hellesdon Hospital were not logging the prescription numbers of prescriptions stored within boxes. Staff did not carry out any audits with regard to unopened boxes held in the storage area, meaning that they would not know if any prescriptions went missing.
  • Overall, only 49% of NSFT employed staff working within substance misuse services had received a yearly appraisal.
  • Staff did not always get a signature from clients on recovery plans to show they agreed to the goals identified, or record in case notes if people had a copy. We spoke with 17 clients; only five clients told us they had been offered a copy of their recovery plan.

12 to 22 July 2016

During a routine inspection

This report describes our judgement of the quality of care provided by Norfolk and Suffolk NHS Foundation Trust. Where relevant we provide detail of each core service, location or area of service visited.

We rated Norfolk and Suffolk NHS Foundation Trust as requires improvement overall because:

  • We found that whilst there had been considerable progress since 2014, the service was not yet safe in all areas, fully effective or responsive at this trust. The board needed to take further and more immediate action to address areas of inadequacy.
  • The trust had reorganised its governance processes and began to use quality information to inform performance. However, the board needed to ensure that their decisions were implemented and brought about positive improvement.
  • We found that whilst performance improvement tools and governance structures were in place these had not always facilitated effective learning or brought about improvement to practices.
  • We had a number of concerns about the safety of some services at this trust. These included unsafe environments that did not promote the dignity of patients; insufficient staffing levels to safely meet patients’ needs; inadequate arrangements for medication management; concerns regarding seclusion and restraint practice.
  • The trust did not have effective systems to record whether staff had received their mandatory training. Many staff had not received regular supervision and appraisal.
  • A lack of availability of beds meant that people did not always receive the right care at the right time and sometimes people had been moved, discharged early or managed within an inappropriate service.
  • Whilst access to a single record had been addressed by the application of a single electronic system, we were very concerned about the performance of this system and the impact this had on staff and patient care.

However:

  • The board and senior management had developed a vision with strategic objectives in partnership with staff and patients and had assumed a leadership role and style that was making a difference.
  • Morale was found to have significantly improved across the trust. This was evidenced by the staff element of the Friends and Family Test which indicated that there had been an increasing level of staff satisfaction since 2014.
  • The trust had undertaken improvement to the environment at some services.
  • The trust had improved systems for recording and learning from incidents.
  • Overall we saw good multidisciplinary working and generally people’s needs, including physical health needs, were assessed and care and treatment was planned to meet them.
  • We observed some positive examples of staff providing emotional support to people.

Throughout and immediately following our inspection we raised our concerns with the trust. The trust senior management team informed us of a number of immediate actions they intended to take to address our concerns.

20-25 October and 6 November 2014

During a routine inspection

When aggregating ratings, our inspection teams follow a set of principles to ensure consistent decisions. The principles will normally apply but will be balanced by inspection teams using their discretion and professional judgement in the light of all of the available evidence.

This report describes our judgement of the quality of care provided within this core service by Norfolk and Suffolk NHS Foundation Trust. Where relevant we provide detail of each location or area of service visited.

Our judgement is based on a combination of what we found when we inspected, information from our ‘Intelligent Monitoring’ system, and information given to us from people who use services, the public and other organisations.

Where applicable, we have reported on each core service provided by Norfolk and Suffolk NHS Foundation Trust and these are brought together to inform our overall judgement of Norfolk and Suffolk NHS Foundation Trust.

We rated Norfolk and Suffolk NHS Foundation Trust as inadequate overall because:

  • We found that there was not a safe, effective or responsive service at this trust and the board needs to take urgent action to address areas of inadequacy.
  • While the board and senior management had a vision with strategic objectives in place staff did not feel fully engaged in the improvement agenda of the trust. Morale was found to be very poor across the trust and staff told us that they felt let down by management.
  • The trust had been involved in a number of initiatives to engage with staff. However, staff told us that leadership from above ward level was not visible or accessible to them. Staff told us that they did not feel engaged in the improvement agenda.
  • Despite the trust collecting data there was little evidence of this being used to inform performance. The board could not assure us that it knew how the trust was performing and how decisions were implemented or impacted on quality. We found that while performance improvement tools and governance structures were in place these had not always facilitated effective learning or brought about improvement to practices.
  • Throughout this inspection we heard from service users, carers and local user groups who felt that they had not been effectively engaged by the trust in planning and improvement processes.
  • We had a number of concerns about the safety of this trust. These included unsafe environments that did not promote the dignity of patients; insufficient staffing levels to safely meet patient’s needs; inadequate arrangements for medication management; concerns regarding seclusion and restraint practice.
  • We were also concerned that while the trust had systems in place to report incidents, improvement was needed to ensure learning or action.
  • A large number of staff had not received their mandatory training and many staff had not received regular supervision and appraisal.
  • A lack of availability of beds meant that people did not always receive the right care at the right time and sometimes people may have been moved, discharged early or managed within an inappropriate service.

However:

  • Overall we saw good multidisciplinary working and generally people’s needs, including physical health needs, were assessed and care and treatment was planned to meet them.
  • We observed some positive examples of staff providing emotional support to people, despite the challenges of staffing levels and some poor ward environments.

It is our view that the trust needs to take significant steps to improve the quality of their services and we find that they are currently in breach of regulations.

Throughout and immediately following our inspection we raised our concerns with the trust. The trust senior management team informed us of a number of immediate actions they intended to take to address our concerns.

Intelligent Monitoring

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up. Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.

Mental Health Act Commissioner reports

Each year, we visit all NHS trusts and independent providers who care for people whose rights are restricted under the Mental Health Act to monitor the care they provide and check that patients' rights are met. Immediate concerns raised by patients on those visits are discussed, if appropriate, with hospital staff.

Our Mental Health Act Commissioners may carry out a number of visits to each provider over a 12-month period, during which they talk to detained patients, staff and managers about how services are provided. In the past, we summarised themes from the visits and published an annual statement followed by the provider's response where applicable. We are looking at different ways to indicate the outcomes of our monitoring in the future.

Other types of report

As well as standard inspection, intelligent monitoring and Mental Health Act Commissioner reports, there are other types of report that we have published under special circumstances.