Last updated: 7 October 2022

Our 'must do' actions

Provided below is a summary of the actions we have delivered to improve safety and care in phase one of our improvement programme. You can view full details here:  Our Improvement Programme[pdf] 5MB (pubished 22 August 2022).

CQC response - Making improvements

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We welcome the feedback that we have had from the Care Quality Commission (CQC) inspection. It means we know exactly where we need to improve.

Our first job has been to focus on immediate safety and quality concerns. Within the report, we received a section 29A notice. It lists the things we must do to meet our legal obligations to the people we care for. 

Our timeline for this evolving work

Phase one: Up to September 2022

The delivery of actions to improve safety, focusing on seven service lines of concern in the Section 29A notice. We are also developing our overarching improvement plan with partners and the public, which will be delivered during phase two.

Phase two: September 2022 – September 2023

This will be about sustaining improvements – focusing on how we work and what we do. This work will be grouped into priorities (see below), delivered with rigorous scrutiny.

More information on these developments, including how these will be sustained, will be discussed at our next board meeting, taking place on September 22nd

Phase three: September 2023 onwards

Our positive changes must last. From September 2023 we’ll focus on continuous improvement and innovation based on a strong foundation.


Improvements made to staffing include:

  • Daily assurance that safest staffing is met on all shifts. ​
  • Significant progress recruiting to nursing and medical vacancies with a net staffing increase of 170 since November 2021.​
  • Further initiatives to support recruitment and retention planned, including staff support and culture development work.  

Mandatory training

Improvements we have delivered to mandatory training include:

  • Training compliance improved to 89% in August 2022 from 83% in November 2021. ​
  • Revised induction programme includes completion of 80% of mandatory and statutory training modules for all new starters. ​
  • PMA training rates have improved significantly however there is more to do to achieve Trust set target. 


The improvements we have delivered to staff supervisions include:

  • Programme to increase Trust-wide compliance and improve data quality delivered. ​
  • Supervision rates have increased to 89% at the end of August 2022 from 62% in November 2021.


Improvements we have made to staff appraisals include:

  • Programme to increase Trust-wide compliance and improve data quality delivered. ​
  • Appraisal rates have increased to 87% at the end of August 2022 from 79% in November 2021. 


Improvements we have made the risk of ligatures include:

  • Remedial works have been completed or are on an accelerated forward plan for Estates work, with mitigations in place to keep service users safe.​
  • Ligature compliance processes strengthened, including regular audits. 

Risk assessments

Improvements we have made to our risk assessments include:

  • Our Quality Safety Reviews show assessments are regularly reviewed. 
  • Our inpatient Care Process Audit shows risk assessments are more regularly reviewed from 87% in March 2022 to 95% in July 2022.
  • Work in progress to develop our assurance process and provide Trust-wide reporting of risk assessments and care plans, as well as local reporting.


Improvements made to the way we hande incidents include:

  • All incidents identified by the CQC have been reviewed and responded to.
  • Through a targeted programme of work, we have reduced our backlog of overdue incidents from 1,300 to 150.
  • We have strengthened escalation processes to ensure that this improvement can be sustained.


Improvements we have made to observations include:

  • Revised processes for conducting and recording observations in a timely way.
  • Audit and CCTV evidence shows improved practice when delivering and recording observations. 

Care and treatment

Improvements we have made to care and treatment include:

  • Sustained improvement with the inpatient Care Process Audit showing more compliance with processes for assessment and care planning from 81% in March 2022 to 90% in July 2022. ​
  • Service users report feeling more involved in their care planning. ​
  • Waiting times for Adult Community services have reduced, with revision to and strengthened application of our Clinical Harm Policy to support those who are waiting. However, we are working with working with commissioners and partners on more timely access.


There has been increased use of the DIALOG+ outcomes measurement tool. Around 2,500 staff have been trained this year.

Privacy and dignity

Improvements we have made to service users' privacy and diginity include:

  • All privacy and dignity related concerns addressed. This includes completion of environmental works in Blickling ward, Poppy ward and our Suffolk Rehabilitation and Recovery Service.
  • We have reviewed protocols at our mixed sex ward (Sandringham) which adhere to Trust Policy, with practice being monitored to ensure ongoing compliance.


Improvements we have made to our governance include:

  • Immediate strengthening of governance processes, with QPMs re-established, a new Board Assurance Framework and monthly audit schedule in place.​
  • External review of local governance completed, with recommendations set to be implemented. ​
  • Governance is an important long-term focus as a Strategic Improvement Theme covering Board, Local and Quality governance.

Medicines management

Improvements we have made to medicines management include:

  • Immediate concerns have been addressed with policies updated with additional compliance checks, with evidenced improvement in areas such as rapid tranquilisation. ​
  • Additional staff have been recruited with strengthened support through supervision and training. ​
  • The Medicines Management strategy has been developed to address the findings of the external review commissioned by the Trust and deliver sustained improvement. 


Improvements made to our culture include:

  • Immediate actions undertaken to improve communication and support staff wellbeing with targeted engagement sessions held. ​
  • More will be done to transform culture from this month. We have recruited 60 culture change agents and 100 wellbeing champions to support staff wellbeing. 

Our priorities

Our Priorities

  1. Ensuring our services are safe; 

  2. Cutting waiting times and improving access to our services;  

  3. Transforming our culture, better staff engagement and creating a fit for purpose organisation with effective governance and leadership; 

  4. Transforming mental health service provision across our counties with our system partners 

Our longer term improvement plan

Our long term improvement actions centre around five themes. Membership includes key staff and is coordinated via dedicated working groups: 

Safety for all
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We’ll develop and support our caring staff to ensure we follow safety and medicines guidance, whilst minimising any risks to safety in the places we offer our care.

Timely access

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We’ll make sure we have enough staff in the right places, whilst working with our partners to ensure people receive care in a timely manner.

Making your voice count 

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We’ll communicate and engage with our staff, leading honestly and sharing positively as a team, whilst delivering jointly owned and understood aims.

Improving governance and leadership 

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We’ll improve our processes along with the information we record and share, ensuring this is recognised and agreed across our services whilst taking responsibility for, and learning from, our mistakes.

Changing services to meet people’s needs 

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We’ll listen to those who use our services and work with them and our partners to improve the quality, safety and consistency of their care and experience. 

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