Turning Point Lincolnshire PHSU Recovery Partnership

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At this assessment we have scored this rating as good. This meant people were safe and protected from avoidable harm.

Leaders and staff consistently demonstrated safe practice across all parts of the service. Staff had a clear understanding of their safeguarding responsibilities and the appropriate escalation pathways, and training compliance rates were high.

Care records showed that risk assessments and recovery plans were completed and regularly reviewed, and prescribing decisions reflected multidisciplinary involvement. Medicines were managed safely, supported by standard operating procedures that were aligned with national guidance and applied consistently. Documentation confirmed that physical health monitoring was carried out for individuals prescribed higher doses of methadone, and naloxone and emergency medicines were readily available.

The environment was clean, well maintained and supported by appropriate infection prevention and control measures. Incident reporting processes were embedded, and staff responded promptly to emerging risks, using de‑escalation techniques and liaising with emergency services when necessary.

Governance structures enabled effective learning from incidents, and staff described clear discharge pathways and collaborative working arrangements with partner agencies to support safe transitions and continuity of care.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Description: We have a proactive and positive culture of safety based on openness and honesty, in which concerns about safety are listened to, safety events are investigated and reported thoroughly, and lessons are learned to continually identify and embed good practices.

We scored the service as 3 (good). The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The staff team fostered a just and restorative learning culture, where incidents and deaths were treated as opportunities for reflection, learning, and service improvement. The organisation’s no‑blame approach supported openness, transparency, and psychological safety. A comprehensive programme of audits, training, shadowing, and structured learning initiatives — including BiteSize Learning and Lincolnshire Learns — underpinned ongoing professional development and promoted the consistent sharing of best practice across the team.

All staff received incident reporting training, with refresher sessions delivered by the governance lead to support effective risk identification and timely learning. Staff responded promptly to incidents and worked to maintain engagement and safety. A clear incident management procedure was in place, supported by an electronic incident reporting system. Staff understood what constituted an incident, how to report concerns, and where to escalate risks. Incidents were routinely discussed during daily FLASH meetings, which provided a structured handover and allowed teams to plan support and address immediate safety issues.

Staff received feedback from incident investigations, including those originating outside the service. Learning was shared through bulletins highlighting both good practice and areas for improvement. Monthly team meetings were held in person but also virtually to maximise attendance provided a forum for discussing incidents and actions taken.

Staff were offered debriefing and support following serious incidents. They also received appropriate induction, supervision and training to ensure they could recognise, report and manage safety events. Managers monitored compliance with learning and development requirements through monthly reporting, and any concerns were addressed through supervision.

Deaths were reviewed monthly through established Mortality and Morbidity meetings, ensuring timely oversight, learning, and responsive action. An annual thematic review was also completed that identified patterns, monitored changes over time, and strengthened understanding of emerging risks. Findings from these reviews directly informed targeted improvement plans for the year ahead.

For example, leaders identified a rise in deaths related to respiratory conditions. This prompted the development of a focused initiative aimed at reducing respiratory harm, improving access to appropriate medication and diagnostic imaging, and addressing identified barriers to timely care.

Description: We work with people and our partners to establish and maintain safe systems of care, in which safety is managed, monitored and assured. We ensure continuity of care, including when people move between different services.

We scored the service as 3 (good). The evidence showed a good standard. The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

We reviewed 10 care records. Risk assessments and recovery plans were present in all files, clearly documented and reviewed at appropriate intervals. Prescribing decisions demonstrated multidisciplinary involvement, reflecting safe and coordinated clinical practice. Staff described structured discharge pathways and effective joint working with hospitals, maternity services, probation and other partner organisations to support continuity of care.

Staff were consistent in outlining their approach to supporting people who exited the service unexpectedly. This included contacting next of kin where appropriate, attempting rapid re‑engagement, and reassessing risk. Care records contained documented unexpected‑exit plans, and we saw evidence in several records that staff acted promptly in line with these procedures by contacting relatives and making repeated attempts to re‑establish contact.

Routine triage took place within seven days of referral, and leaders described an urgent pathway for people identified as high risk to ensure timely assessment and intervention.

Leaders had identified timely access to the service as a potential risk, which was monitored regularly through the service‑level risk register. Actions taken included updating the referral review process, holding frequent reviews of performance data, and allocating dedicated triage appointments. These measures were monitored on an ongoing basis to ensure they remained effective.

A coordinated, multi‑agency response to drug alerts was established across Lincolnshire. Commissioners and strategic partnership forums oversaw this process, ensuring a consistent and collaborative approach. Within Lincolnshire Recovery Partnership (LRP), the Harm Reduction Lead was responsible for managing alerts, facilitating timely communication and implementing actions to minimise harm to service users. A joint formulary is used consistently across Lincolnshire, supporting safe and standardised clinical practice.

LRP maintained strong partnerships with the regions ambulance service through a simplified referral process, enabling early identification of need and proactive engagement with individuals following ambulance contact. Dedicated hospital liaison workers were co‑located within acute settings, facilitating seamless transfers of care and integrated support.

LRP played an active role in system-wide collaboration, contributing to the Lincolnshire ICS Inclusion Health Oversight Group and provided specialist substance use expertise. Co‑location, shared training, and shadowing opportunities strengthened pathways and promoted integrated working, including with mental health services.

In response to the increased risks associated with synthetic opioids, LRP developed a staged response guide that supported proactive harm reduction, multi‑agency coordination, targeted outreach, and prioritised naloxone distribution.

Clinical governance was supported through regular national meetings attended by clinical services managers, ensuring practice remains aligned with emerging guidance and national priorities.

LRP also worked closely with the perinatal mental health team, safeguarding midwife, and wider midwifery services. A clear referral pathway enabled direct referrals and ensured pregnant women and new mothers receives timely and appropriate support.

Description: We work with people to understand what being safe means to them as well as with our partners on the best way to achieve this. We concentrate on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect, and we make sure we share concerns quickly and appropriately.

We rated the service as 3 (good). Evidence showed that the service worked effectively with individuals and healthcare partners to understand what safety meant to them and how best this could be achieved. The service maintained a strong focus on promoting people’s wellbeing while protecting their rights to live safely and free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. Concerns were identified and escalated promptly through appropriate channels.

The LRP safeguarding working group met monthly to review safeguarding activity and drive ongoing improvement in practice. The group was chaired by a dedicated safeguarding manager, who also served as the organisation’s safeguarding lead, providing consistent guidance, oversight, and support to staff across the service. Each hub held a monthly safeguarding action learning Set (SALS) meeting, providing staff with a structured forum to discuss cases, reflect on learning, and review the effectiveness of safety plans. These sessions also offered direct support and professional guidance from the safeguarding manager, reinforcing consistent and safe safeguarding practice across the service.

Staff demonstrated a clear understanding of safeguarding responsibilities and escalation routes. They had access to a safeguarding lead and regular weekly safeguarding meetings, which ensured ongoing oversight and support. Overall training compliance was high with 84% of staff up to date with safeguarding training.

Between 3 December 2025 and 3 March 2026, the service reported 16 safeguarding incidents. Each incident was managed promptly and in accordance with safeguarding procedures, ensuring that appropriate actions were taken to protect people from harm and maintain a safe environment.

Staff were able to identify adults and children at risk of, or experiencing, significant harm and worked effectively with partner agencies to ensure people were protected. Designated safeguarding leads were in post and attended external multi‑agency forums, including MARAC (Multi‑Agency Risk Assessment Conferences). A range of internal safeguarding meetings took place, from monthly to quarterly, providing governance oversight of safeguarding activity and emerging concerns.

Staff had access to local safeguarding protocols and organisational safeguarding policies and procedures. Managers maintained oversight of safeguarding alerts through the electronic reporting system to ensure timely action and compliance.

The service also took practical steps to promote safety in people’s homes and temporary accommodation. For example, peoples were provided with lockable medicine storage boxes, offering an added safety measure for individuals with children or those without a fixed address.

Description: We work with people to understand and manage risks by thinking holistically so that care meets their needs in a way that is safe and supportive and enables them to do the things that matter to them.

We rated the service as 3 (Good). Evidence showed that the service delivered a consistently good standard of care. Staff worked collaboratively with people to understand and manage risks, taking a holistic approach to support safety and wellbeing.

Staff completed comprehensive risk assessments for each person, clearly documenting historical and current risks. These included predisposing, precipitating and protective factors, enabling staff to recognise when a person’s risk profile changed and to respond appropriately. Care provided was safe, supportive and aligned with what mattered to people.

People were actively involved in developing their care plans and risk assessments, and records confirmed that they were offered copies of their plans. Staff communicated effectively with individuals to ensure they understood their care and treatment, including adapting approaches for people with communication needs. We saw treatment information available in multiple languages and a neurodiversity handbook to support people with neurodiverse conditions.

Records showed that risk assessments were completed and reviewed regularly. Incident records demonstrated timely and appropriate actions, including the use of de‑escalation techniques and liaison with emergency services when required. People using the service understood group rules and the implications when someone attended under the influence. Care records showed that staff sought to maintain engagement and clarify expectations following incidents.

Risk management plans were updated following any changes in circumstances, and people using the service—and their carers where appropriate—confirmed they were informed and involved in these updates.

Staff encouraged people to provide feedback through surveys and feedback forms. We saw evidence that the service acted on this feedback, resulting in adjustments and improvements to how care was delivered.

Description: We detect and control potential risks in the care environment and make sure that the equipment, facilities and technology support the delivery of safe care.

We rated the service as 3 (Good). Evidence demonstrated that the service had effective systems in place to identify, monitor and control environmental risks, ensuring that equipment, facilities and technology supported the delivery of safe, high‑quality care. Leaders and staff showed a clear understanding of their responsibilities in maintaining safe environments across all hubs.

At the time of our visit five out of the six hubs had undergone refurbishment or been relocated to enhanced premises. All environments were fully disability discrimination act (DDA) compliant and had been developed in line with trauma‑informed design principles. Further improvements were planned to ensure all sites remained welcoming, safe, and supportive for both service users and staff.

All hubs operated to a consistent standard, supported by a comprehensive programme of audits and checklists that maintained a safe and inviting environment. Lone working arrangements were risk assessed, with digital systems in place that promoted staff safety during outreach activity. Business continuity plans and routine medical device audits were embedded, ensuring services remain effective, resilient, and responsive.

Staff carried out regular and comprehensive environmental risk assessments, which were recorded and followed up with clear actions. These assessments covered general health and safety risks, building security, infection prevention measures and the suitability of clinic spaces. Fire safety processes were well‑established. Fire alarm systems were tested weekly in all hubs, and each location displayed up‑to‑date information identifying the appointed fire wardens. Fire drills were completed quarterly, providing staff with regular opportunities to rehearse emergency procedures and ensure that all personnel were confident in evacuating the premises safely and efficiently. All hubs were equipped with suitable fire alarm systems in every room accessed by people, supporting rapid detection and response in the event of an incident.

Clinic rooms were consistently well equipped to support safe clinical practice. Each room contained accessible resuscitation equipment and emergency medicines, which were checked regularly in line with organisational policy. Emergency medicines included naloxone—an essential medication used to rapidly reverse the effects of opioid overdose—demonstrating the service’s preparedness to respond promptly to emergencies involving people who use substances. Records showed that checks of emergency equipment were completed as required, with out‑of‑date items replaced promptly.

The service had clear arrangements for the safe collection, storage and disposal of clinical waste. Clinical waste bins were appropriately labelled, securely stored and collected routinely by an approved contractor, reducing the risk of contamination or environmental hazards. Staff demonstrated an understanding of waste segregation procedures and the importance of maintaining infection control standards.

Equipment used within the service was maintained to ensure it remained safe and fit for purpose. Portable appliance testing (PAT) was completed at required intervals, and hubs kept up‑to‑date inventories of electrical items to ensure compliance. This supported a safe working environment for both staff and people.

People described the premises positively, noting that environments were clean, quiet and private. People felt comfortable, safe and respected within the hubs. One person commented, “I couldn’t ask for a better building. It’s clean and safe. I am always able to use the toilet and make myself a hot drink.” This feedback reflected a supportive and welcoming environment that aligned with the service’s aim to provide safe and accessible community‑based care.

Description: We make sure there are enough qualified, skilled and experienced people, who receive effective support, supervision and development and work together effectively to provide safe care that meets people’s individual needs.

We rated the service as 3 (Good). Evidence demonstrated that the service consistently ensured there were sufficient numbers of qualified, skilled and experienced staff who received appropriate support, supervision and opportunities for development. Staff worked collaboratively to deliver safe care that met people’s individual needs.

Across the Lincolnshire Recovery Partnership (LRP), a large multidisciplinary team was in place with a wide range of professional skills and experience. The service had not required the use of agency staff over the previous six months at the time of our assessment, as staff with transferable skills provided effective contingency to manage fluctuations caused by sickness or staff turnover. Although agency staff had not been required in the past six months, robust processes were in place should they be needed. These aligned with recruitment policies and ensured all agency staff had up-to-date disclosure and baring service (DBS) checks and the appropriate skills and qualifications. No concerns were raised by staff during the assessment, and staff provided positive feedback regarding workload management and support from leaders.

All hubs held a daily flash meeting to review priorities and planned activity for the day. These meetings ensured that all areas of the service were appropriately covered and staffed, supporting a coordinated and safe approach to service delivery.

Case management audit sessions were carried out by leaders, and individualised support plans were implemented where required to help staff manage workload pressures. This approach strengthened oversight and promoted safe and effective caseload management.

Staff received regular and structured one‑to‑one supervision. Leaders shared that the 1:1 staff supervision template had been redesigned following staff feedback and was standardised across all three partner organisations, ensuring equity and consistency in the quality of supervision. The tool included a focus on staff wellbeing, reflective practice, and development. All staff also received an annual appraisal, with compliance monitored through a local quality and governance tracker.

Safer recruitment processes were in place, including pre‑employment checks, structured induction and verification of professional registration for relevant staff. At the time of our assessment 100% of colleagues were compliant within the organisations DBS policy.

All staff completed their mandatory training within their six‑month probation period, supported by additional local LRP training to strengthen core skills. Ongoing refresher training ensured staff-maintained competence, remained up to date with current guidance, and adapted to emerging changes in practice. At the time of our visit LRP training compliance stood at 90% overall, which included new staff still progressing through their probation period and staff on long‑term absence or maternity leave.

Staff were actively invested in and supported to develop within the organisation. A range of leadership development and coaching opportunities were available for both current and aspiring managers, promoting strong leadership across the service. A variety of apprenticeships were accessible to all staff. Employees of Turning Point, Framework, and Double Impact all had access to each organisation’s training and apprenticeship programmes, ensuring equitable opportunities across the service.

Description: We assess and manage the risk of infection, detect and control the risk of it spreading and share any concerns with appropriate agencies promptly.

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

All areas that we visited were visibly clean, well‑organised, and maintained to a high standard. Clinical and non‑clinical areas were free from clutter, and consumable items were stored appropriately and consistently found to be in date. The service’s Infection Prevention and Control (IPC) arrangements were proportionate to its risk profile. Appropriate ventilation was in place, and staff had ready access to sanitising products, bio-spill kits, and correctly assembled sharps bins positioned at the point of use.

Records demonstrated that the provider maintained an up‑to‑date IPC risk assessment which was reviewed and updated in line with service changes. Ongoing monitoring was carried out routinely, with clear documentation of any remedial actions taken where readings fell outside expected parameters. Issues requiring external contractor support were escalated promptly and followed through to completion, evidencing good oversight and governance.

Staff were observed to follow infection control principles in line with national guidance, including appropriate use of personal protective equipment (PPE), hand hygiene practice, and safe disposal of clinical waste. Staff understood their responsibilities and could describe the procedures that supported safe working practices.

The provider had comprehensive IPC policies and procedures in place that reflected current best practice and national guidance. Cleaning schedules and checklists were available for all areas of the service, and these were consistently completed, demonstrating an established system for ensuring ongoing cleanliness and environmental safety.

Description: We make sure that medicines and treatments are safe and meet people’s needs, capacities and preferences by enabling them to be involved in planning, including when changes happen.

We scored the service as 3. The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

Medication errors were reported through the providers electronic incident reporting system. Incidents were risk‑rated and accompanied by action plans to address any identified harm. Learning was shared through the Lincolnshire learns newsletter, promoting a culture of openness, reflection, and continuous improvement, including learning arising from medication‑related incidents. We reviewed medication audits between 03/12/2025 and 03/03/2026 and found seven medication errors across the six LRP locations. All incidents were fully investigated in line with organisational procedure, and no harm was caused to the patients involved. All affected patients were informed of the incidents and kept updated as required.

Staff demonstrated safe and effective practice in all aspects of medicines management, including ordering, recording, storing, and administering medicines. Their approach reflected current national guidance, and relevant policies were readily accessible to support consistent practice across the service. LRP hubs did not routinely store controlled drugs on site. Buvidal medications were collected and administered in line with a robust policy to ensure safe practice, while all other controlled drugs were accessed by service users through established pharmacy agreements.

Medicines were managed in a way that promoted safety and person‑centred care. People using the service received clear explanations about their medicines and felt involved in decisions regarding their treatment plans. Staff described how they used national and regional clinical forums to discuss complex cases, share learning, and support safe decision‑making. They also outlined how clinical supervision encouraged reflective practice and contributed to safe prescribing. Staff were able to explain how they worked collaboratively to identify and mitigate risks, for example by monitoring for signs of misuse or diversion and adjusting treatment plans when necessary.

The service had detailed standard operating procedures (SOPs) for all prescribing pathways, including opioid substitution therapy, detoxification, and relapse‑prevention treatments. These SOPs reflected relevant national guidance, including National Institute for Health and Care Excellence (NICE) recommendations, and staff were familiar with their content. Staff explained how they applied these procedures in day‑to‑day practice.

We reviewed ten care records across different treatment pathways. Records were consistently completed and demonstrated clear documentation of prescribing decisions, physical health monitoring, and risk assessments. For example, electrocardiogram (ECG) monitoring was recorded where clinically indicated, such as for peoples taking higher doses of methadone. Interviews with staff and a review of clinical documentation confirmed that SOPs were being followed and that prescribing decisions were subject to appropriate oversight and governance.

The service stocked Naloxone, used to reverse opioid overdoses, and offered this to people as part of harm‑reduction practice. Staff provided training to ensure people knew how to use Naloxone safely and effectively. Sharps bins were available and used appropriately for the safe disposal of needles.

People were also offered secure storage boxes to keep their medicines safely at home, particularly where children were present, to reduce the risk of accidental ingestion.

People using the service consistently reported that they received their medicines on time and as prescribed.