Lincolnshire Partnership NHS Foundation Trust

Updated 22 June 2020

Not used

Updated 22 June 2020

We have not updated trust-level ratings following this core service inspection because we were not able to complete the trust-level well-led inspection. This is due to suspension of routine inspections during the COVID-19 pandemic. Refer to the previous inspection report for the detailed findings on which the ratings are based.

Updated 11 June 2025

Lincolnshire Partnership NHS Foundation Trust provides five acute wards for adults of working age across four locations: Ash Villa in Sleaford (15-bed female ward), Ward 12 in Boston (20-bed mixed ward), and Ellis Ward (20-bed male) and Castle Ward (20-bed female) in Lincoln. For this assessment we carried out on-site inspections of Ward 12, Castle Ward and Ellis Ward on 17 and 18 June 2025. The visit was unannounced, meaning the provider was not informed in advance. We returned to the wards on 01 July 2025 to ensure that action had been taken to address our concerns. Actions had been taken and we noted improvements in these areas. The service was last rated Good in June 2024 under CQC’s former inspection framework. This assessment was completed using the new Single Assessment Framework (SAF) and focused on the key questions of Safe, Responsive and Well-led. The assessment was prompted by concerns raised anonymously. Whilst the Trust had identified issues with repeated legal breaches in the use of rapid tranquilisation and had instigated regular audits of compliance that were reported through the governance structure, escalation processes were not sufficiently swift or robust enough to ensure timely board. Due to the insufficient speed and robustness of escalation processes the Board was unable to enact its duty of candour responsibilities when rapid tranquilisation was given outside the legal framework of the Mental Health Act 1983. Staff were not consistently trained or competent in the legal and clinical requirements for rapid tranquilisation. We identified 32 instances where it had been administered without the required authorisation or recorded consent. The trust investigated these concerns and confirmed there were 26 incidents which related to 8 patients when rapid tranquilisation was administered. The trust determined through this investigation and reviews by the local authority and ICB safeguarding leads no harm was caused to the patient and the intervention was clinically indicated. However, the confirmed the necessary safeguards were not in place. Risk assessments were not always accurate or robust, meaning staff did not have clear guidance to manage current risks. Care plans were often generic and not written in the patient’s own voice, and important assessments - such as an autism diagnosis - were not always reflected. While some patients reported positive support - such as help to continue education or maintain family contact - these experiences were not consistent across the wards. Senior Leaders did not demonstrate capable leadership or strong governance in relation to ensuring compliance with elements of the Mental Health Act 1983 and consistent application of person centred- care through care planning and risk assessments. Some staff reported fear of speaking up despite the Trust having a well promoted Freedom to Speak Up Policy, a dedicated Freedom to Speak Up Guardian, several Freedom to Speak up Champions and has Speaking Up as part of its organisational induction and mandatory training. These failings meant that patients were exposed to avoidable harm, delays in discharge and breaches of their legal rights. We found 3 breaches of regulations 11, 12 and 17. We have taken action in response to these breaches of regulation. We issued the provider with a warning notice for: Regulation 11 (Consent to treatment) Regulation 12 (Safe care and treatment) Regulation 17 (Good Governance) You can find more details of our concerns in the report.

Updated 20 August 2025

The Vales is a female only ward that has 15 beds. It specialises in providing rehabilitation to people who are suffering with long term mental health disorders, including person’s detained under the Mental Health Act 1983.

We visited the Vales on 17 and 18 September 2025 and again on 1 October 2025 in response to concerns about patient and staff safety.

The Fens is a male only ward that has 15 beds. It specialises in providing rehabilitation to people who are suffering with long term mental health disorders, including person’s detained under the Mental Health Act 1983.

The Fens was visited as part of this inspection on the 18 September 2025.

The ward environment was clean, well maintained and suitable for the needs of the patient group. Staffing levels generally met the planned establishment, Medicines were managed safely, and infection prevention and control standards were good.

Whilst leaders on the Vales had taken steps to strengthen physical-health monitoring and oversight through new assurance processes and daily checks, these were not embedded. This placed patients at risk. Staff were not all trained or competent in essential clinical skills such as neurological observations and enteral feeding, and gaps in physical-health monitoring continued despite recent improvement initiatives. Incidents involving ligatures, assaults and airway obstruction continued to recur, and the severity of harm was sometimes underestimated in incident grading. This limited the ward’s ability to recognise risks, learn effectively and prevent recurrence.

The Vales had developed a quality improvement plan to strengthen governance, culture and staff competence. While this plan provided structure and oversight, many actions were still in progress with completion dates extending into 2026. Learning from incidents, safeguarding enquiries and physical-health concerns was not yet embedded into governance or daily practice. Repeated issues with record keeping, nutrition and hydration monitoring, and escalation of deteriorating health remained evident across care records and assurance documentation.

Leadership visibility and accountability on the Vales had improved following the appointment of a new clinical lead, service manager and improvement lead. Governance structures were in place, including daily oversight meetings and regular reporting to the Quality Review Meeting and Performance and Delivery Oversight Group. Leaders were honest about the challenges faced by the service and demonstrated commitment to improvement. However, governance, culture and learning systems were not yet mature enough to ensure that improvements were sustained, embedded or that care was consistently safe and high quality.

Due to the level of risk identified, the Care Quality Commission issued a Notice of Proposal (NOP) under Section 12 of the Health and Social Care Act 2008, requiring the trust to improve staff competence in physical-health monitoring, strengthen daily assurance processes, independently review incidents of harm, and enhance board-level oversight and learning on the Vales. We found breaches in regulations 12, 14, 17 and 18.

Updated 31 October 2024

Lincolnshire Partnership NHS Foundation Trust delivers a range of community-based services to the people of Lincolnshire. The Trust’s community mental health teams were last rated as Good during our inspection in October 2018, published 16 January 2019. We inspected these community-based mental health services for adults of working age as part of our ongoing comprehensive mental health inspection programme. The report was published following CQC’s old inspection approach using key lines of enquiry (KLOEs), prompts and ratings characteristics. This assessment was completed following CQC’s new approach to assessment; Single Assessment Framework (SAF).

We carried out our on-site responsive assessment on 21st November 2024. This was an unannounced focused assessment in response to concerns received about the service. The service was not told that an assessment was going to take place. During this assessment we inspected one quality statement under safe, one under effective and one under caring. At this assessment we rated the service as good as this service is performing well and meeting our expectations

Updated 9 June 2017

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

• The ward was clean, tidy and well maintained. Observation mirrors and closed circuit television was used to assist nursing staff with observations.

• The ward had an up to date ligature risk audit, staff mitigated the risk on the ward by observing patients. Staff mitigated the risks posed in the garden area by accompanying patients when they wanted to access the garden.

• The ward had sufficient staff to provide good care and treatment to patients.

• The ward met the criteria for eliminated mixed sex accommodation in line with guidance contained in the Mental Health Act code of practice.

• Staff were 98% compliant for mandatory training.

• Staff undertook a risk assessment with every patient upon admission. Care plans were comprehensive, personalised, holistic, and recovery orientated.

• Staff provided a range of therapeutic interventions in line with the National Institute for Health and Care Excellence guidelines and there was a full education programme in place.

• Staff read detained patients their rights on admission and regularly thereafter. Staff gave patients an information leaflet explaining their rights and responsibilities as an informal patient.

• Overall, 100% of non-medical staff had an up to date appraisal.

• There was a well-functioning multidisciplinary team. Staff discussed patients’ care and treatment weekly in ward round. Parents told us that they felt involved in the care and treatment.

• Patients told us that they felt supported to make their own decisions and staff treated them with dignity and respect. Patients said they were involved in their care plan.

• Staff interacted with patients in a positive way. All staff demonstrated a good understanding of patients’ individual needs, including care plans, observations and risks.

• The ward had a range of rooms and equipment to support treatment and care. There was a large garden; with an area that had been made secure. Patients could personalise their bedrooms and could choose from a choice of bedding.

• There was a family room for parents, carers and siblings to visit. Visits within the community and the garden area were also encouraged.

• There was access to activity across the week with primarily nurse led sessions over the weekend. Patients worked with the activity coordinator to plan activities that they would like to do.

• All staff demonstrated the trust values in their behaviour and attitude. Staff we spoke with were passionate about helping patients with mental illness. Staff were proud of the work that they carried out and the care that they provided to patients.

• Managers told us they had sufficient authority to complete their role and they felt supported by senior managers.

However:

• Staff kept most doors on the ward locked. There was no clinical justification for this practice and it was not individually care planned. This was a blanket restriction.

• Seventy-one per cent of staff had undertaken training in clinical risk assessment and management. This was below the trust target of 95%.

Updated 9 June 2017

We rated Lincolnshire Partnership NHS Foundation Trust specialist community mental health services for children and patients as outstanding because:

• Patients and carers told us that everyone was caring, compassionate, kind and treated them in a respectful manner. All feedback surveys collected by the trust were consistently positive about the way that staff treated patients.

• The service had established an innovative model of working using outcome measures at each appointment. This model was patient centred and holistic based around the child or young persons’ strengths and goals.

• Staff were open and transparent in relation to incidents and complaints. They acted on lesson learnt from incidents and complaints. They strived to continually improve the service they delivered by working closely with commissioners and other stakeholders.

• Managers and senior staff including board members were visible and approachable. Staff expressed they felt able to raise concerns without fear of reprisal. The managers and team co-ordinators were passionate about delivering high quality care and treatment and had funded 17 clinicians to undertake children and young people’s improving access to psychological therapies training. They had managed to recruit to the 17 vacancies with substantive posts therefore increasing the level of staffing within the service.

• Risk assessments and care plans were comprehensive and well written. They were developed in collaboration with the patient and, where appropriate, their carers. Staff were able to refer patients to the crisis and home treatment and resolution service within CAMHS if they were concerned about a young person’s presentation out of hours and at weekends. This service had been praised highly by senior staff at the local hospitals in relation to the responsiveness of the team Communication between the teams was excellent.

• The service had introduced an animal assisted therapy service to group work for patients.

However:

• Only 68% of staff had undertaken the children’s safeguarding training level 3B.This was below the trust target of 95%.

• Staff supervision rates were lower than the trust expectations and managers did not always keep a record of supervision sessions.

Updated 16 January 2019

The summary for this service appears in the overall summary of this report.

Updated 9 June 2017

We rated community based community mental health services for older people as good because:

• All patient information was stored electronically and was accessible to staff.

• The service followed National Institute for Health and Care and Excellence (NICE) guidance in prescribing medication and reviewing patients who had dementia.

• Patients were consistently positive about the centres and about the staff, patients felt understood and cared for.

• Patients told us that they felt involved in their care planning and that they had been offered a copy of their care plan.

• Staff were able to prioritise and see urgent referrals quickly.

• There was a safeguarding champion available to support staff with safeguarding concerns and safeguarding posters were displayed in the reception areas at each of the locations.

• Staff learned from incidents, complaints and patient feedback via the bi monthly lessons learned bulletin, at team meetings and during supervision. We saw examples of lessons learned and changes in practice as a result of this.

• Leaflets were available in different languages and information was available in different formats on request.

• Staff were passionate about their jobs and used the trusts’ vision and values in their everyday work.

• Senior managers were visible and known to staff. They visited the locations to update staff on changes within the service and the trust.

• Sickness and absence rates were low and clear strategies were in place to cover any staffing shortfalls.

Updated 9 June 2017

We rated mental health crisis services and health-based places of safety as ‘good ‘because:

•  The trust had taken actions to improve the environment of the health based place of safety and to increase the range of multi-disciplinary staff in crisis teams following our last inspection.
• Staff completed risk assessments for all patients and updated them as the level of risk changed.
• Many patients felt their mental health had improved as a result of the service they received from the crisis and home treatment teams.
• The trust took action to address the changes to the Policing and Crime Act 2017 and had identified inpatient beds to ensure patients were not kept longer in the health based place of safety than needed.
• Managers reviewed discharge processes for inpatients to ensure they did not remain in hospital longer than was needed. For example, they reviewed the use of the crisis house, improved communication with discharge coordinators and bed managers.
• The trust arranged crisis team support based out of hours with the police to signpost patients to mental health services.
• The trust met commissioned targets for contacting patients within four hours.
• The trust had plans to develop a clinical decisions unit in 2018 to further support patients in crisis needing hospital admission.
• Grantham crisis and home treatment team had achieved the Royal College of Psychiatrists home treatment accreditation scheme.

However

• The trust had not ensured that staff regularly received clinical and managerial supervision.
• Patients and carers did not have copies of their care plans explaining the support teams would give them.
• Staff did not consistently document that they had assessed patients’ physical health care needs.
• Crisis team staff said that patients could wait for hours to be transferred to out of area placements due to delays with the contacted transport service being able to respond and escort them.
• Crisis teams did not include psychologists which meant assessments of patients at the point of crisis were not fully multi-disciplinary.
• Staff morale in Louth was lower than other teams because of increased work due to the community mental health teams and difficulty accessing medical cover.
• The trust had not ensured that all staff completed mandatory training for their role.
• Trust information from April 2016 to March 2017 showed staff had not completed the patient’s discharge time on records on 127 occasions.

Updated 9 June 2017

We rated forensic inpatient/ secure units as good overall because:

• Francis Willis was a slightly dated but pleasant environment. There were clear lines of sight throughout the ward. The trust has completed detailed ligature risk assessments and plans were in place to appropriately manage these risks within the unit.

• The defibrillator and essential safety equipment had been serviced and regular checks were undertaken.

• There was sufficient staffing during weekdays and the unit had medical support at all times. Staff had undertaken mandatory training and received regular supervision and appraisal

• Nursing staff on the wards were enthusiastic in their approach and patients spoke positively about them. The clinical team contained full multi-disciplinary representation.

• All admissions were planned following pre admission assessments. Local risk assessments were also carried out after admission. Patient care plans were personalised and based around the individualised risk.

• All patients had their physical healthcare needs met and there was an effective health care recording system

• Leadership on the unit was highly visible and managers had a positive presence on the ward.

• Areas of concern highlighted following our previous inspection had been addressed.

  However:

• We remain concerned about the safety of the garden area of the ward. This contained potential ligature points and additional safety risks that had not been addressed through environmental risk management plans. Staff managed these risks through restricting patient access.

• We found some other examples of blanket restrictions. These included access to mobile phones and set vaping times.

• While patients had a good level of activity and escorted leave during weekdays there were limited activities available at weekend.

Updated 9 June 2017

• Ligature points (places to which patients intent on self-harm might tie something to strangle themselves) were identified as part of the monthly environmental risk assessment audit and actions had been identified to reduce the risk to patients. These included enhanced observation levels. Wards complied with the Department of Health’s eliminating mixed sex accommodation guidance, which meant that the privacy and dignity of patients was upheld.
• Cleaning rotas had been completed and the wards were visibly clean and tidy. Nurse call systems were in place in bedrooms, communal and office areas.
• Staffing levels were appropriate to meet the needs of patients. There were low levels of both qualified and unqualified nursing vacancies. Ward managers were able to adjust staffing levels to take account of clinical need and said senior managers never refused a request for additional staffing if required. Escorted leave and activities were rarely cancelled due to staff shortages.
• Staff followed National Institute for Health and Care Excellence (NICE) guidelines in relation to practice and when prescribing medications. These included regular reviews and physical health monitoring. Patients were supported to access specialists when required for physical healthcare needs. Hydration and nutrition were monitored regularly and recorded in care records.
• Staff and patients interacted well. Staff managed distressed patients in a calm and responsive way and supported them to talk about the issues affecting them. Staff knew the patients very well and were passionate about patients' needs. Patients told us that they had good relationships with staff and they were very helpful, understood their problems and were always available. They said they felt safe and that staff took the time to listen to them when they had a problem.
• Hot drinks and snacks were available on request 24 hours a day. Patients were able to personalise their bedrooms.
• Staff told us who the most senior managers in the trust were and that they had visited the wards. Ward managers told us they felt well supported by their line managers.

However:

• Staff did not always review risk assessments following incidents.
• There was limited access to psychological therapies. The service had one whole time consultant psychologist and one whole time assistant psychologist for both community and inpatient older adult services.
• Trust data showed supervision rates across the service between January 2017 and March 2017 to be 66%. The trust could not be assured that performance issues and training needs were identified or acted upon.
• Capacity assessments were not decision specific, forms included more than one question.
• One patient was receiving covert medication, we did not find a capacity assessment form for this.
• There was little evidence of patient participation in care plans and risk assessments. Four patients reported that they had not seen or been provided with a copy of their care plan.
• Patients had a lockable drawer in their bedroom; however keys were not available for patients to lock the drawer.