A damning inspection into the region's mental health trust has highlighted a large number of failings - but also emphasised the caring nature of its staff.
Inspectors from the Care Quality Commission identified a long list of concerns the Trust needed to take on board if it is to finally turn around its fortunes.
These are just some of the things it identified:
1. The Trust must learn to listen to others better
The report praised the hard-working nature of those working on the front line - but had concerns the Trust's leaders often ignored their concerns.
It states: "The Trust must ensure that senior managers are visible, approachable and listen to the staff concerns and opinions."
2. Children were restrained incorrectly
While the report noted some improvements in children's mental health services since a 2020 inspection, concerns were raised about use of restraint on the ward for young people.
It reads: "We were concerned the levels of restrictive intervention used on the ward were high. We could not be sure all physical restraint procedures were carried out correctly or safely."
3. Staff levels continue to be a problem
The report says: "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 the safety staff and patients feel."
4. Ligature points were not removed
A deeply concerning aspect of the report referred to ligature points - places from which people can attach ropes and similar items associated with hanging.
The report states: "The Trust did not ensure staff were aware of ligature assessments or mitigated or removed ligature points effectively to maintain patient safety."
5. Young people struggle to access services
Inspectors highlighted just how much demand from young people the Trust is facing.
The report says: "The service was not easy to access - waiting lists were long.
"There are a high number of active referrals, which grew from a low of 95 in August 2020 to 2,547 in July 2021."
However, overall, the service offered to young people had improved from the last report - when this aspect was judged inadequate.
6. Problems on a children's ward
Shortcomings were highlighted on the hospital's Dragonfly ward in Carlton Colville, a children's which was closed to new patients for extensive periods.
The report says: "Severe deterioration was found on the... ward. This service relied on agency workers and lacked a permanent doctor.
"Its staff did not have appropriate training to protect young people from avoidable harm or build care around their individual needs, leading to a high use of restrictive interventions which inspectors were unassured were undertaken safely or correctly."
7. Staff came in for praise
Amid the many difficulties the Trust faces, its front line staff were highly praised.
The report states: "Staff were discreet, respectful and responsive when caring for patients.
"Staff gave patients help, emotional support and advice when they needed it.
"Patients provided positive feedback about how staff treated them."
Craig Howarth, CQC head of inspection for mental health and community services, said: “Although the quality and safety of patient care in most of the services we inspected at Norfolk and Suffolk NHS Foundation had deteriorated since our previous inspection, there were areas where we found improvement.
“A significant factor behind the Trust’s shortcomings was its lack of enough staff to meet patient need, a problem many mental health trusts are encountering. The Trust needs to ensure its leaders have effective processes to consistently monitor teams, ensure compliance with training targets, understand issues affecting patient care and do more to support staff on the front line.
"However, we found staff were more engaged, compared to our previous inspection, driven by a vision of what the Trust wanted to achieve for its patients."
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