CQC Report: NSFT ‘Requires Improvement’ but Safety remains ‘Inadequate’


Look beyond the spin from the Board of Norfolk and Suffolk NHS Foundation Trust (NSFT).

The Care Quality Commission (CQC) confirms our concerns about beds, staffing, safety and increasing numbers of patient deaths at NSFT.

Not enough staff:

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.

Not enough beds:

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.

Lorenzo is very poor and dangerous:

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.

NSFT is unsafe and there are too many deaths:

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

  • We found a number of environmental safety concerns. Whilst some work was being planned or underway to remove potential ligature risks, we were concerned that planned actions would not adequately address all issues. We also found that the layout of some wards did not facilitate the necessary observation of patients.
  • The trust had not ensured that all mixed sex accommodation met guidance and promoted safety. Some seclusion rooms and dormitory areas did not promote privacy and dignity.
  • We were concerned about the design of seclusion and place of safety facilities across the trust and that seclusion was not managed within the safeguards of the Mental Health Act Code of Practice.
  • We were concerned that staffing levels, including medical staff, were not sufficient at a number of inpatient wards and community teams across the trust.
  • The trust had not ensured that all staff had sufficient mandatory training. Of particular concern were levels of training in restrictive intervention and life support.
  • The trust had not ensured that all risk assessments were in place, updated consistently in line with changes to patients’ needs or risks, or reflected patient’s views on their care.
  • There had been significant work carried out to reduce restrictive intervention and overall rates had reduced. However, data provided by the trust showed that restraint remained above average and levels of prone restraint remained high in acute and learning disability services.
  • The trust had systems in place to report incidents however we found a number of incidents across the trust that had not resulted in learning or action. The trust had identified that there had been a high number of deaths of community patients and had commissioned an independent review to look in to this. The trust was addressing the issues that were highlighted through this work however we are concerned that overall rates of death remain high at the trust.
  • Arrangements were not adequate for the safe and effective administration, management and storage of medication across the trust. The trust was not compliant with Controlled Drug legislation when ordering controlled drug medication from another trust. The trust had not consistently maintained medication at correct temperatures in all areas or ensured action was taken if it was found to be outside correct range.

What could be more important than safety and increasing number of patients dying unexpectedly?

Normally, when a trust enters special measures, the NHS takes action to ensure proper funding.

The Department of Health, commissioners and NHS England have done virtually nothing to address the £70m annual shortfall in NSFT’s budget.

What are caring front line staff supposed to do without enough colleagues or beds?

1 thought on “CQC Report: NSFT ‘Requires Improvement’ but Safety remains ‘Inadequate’”

  1. At last the inadequacies of the Trust are acknowledged by CQC. OK the Trust has improved, but it is still woefully under-resourced, both financially and with inadequate staff to make services safe.

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