Turning Point Lincolnshire PHSU Recovery Partnership

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well led- This means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At this assessment we have given the rating Good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

Leaders had the skills, knowledge and experience to perform their roles. Staff knew and understood the provider’s vision and values and how they applied to the work of their team. Staff felt respected, supported and valued. Governance processes operated effectively. Performance and risk were managed well. Teams had access to the information they needed to provide safe and effective care. Staff collected analysed data about outcomes and performance. They used this to identify improvements.

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 shared vision, strategy and culture that is based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding and meeting the needs of people and our communities.

We scored the service as 3. The evidence showed a good standard. The service had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Staff demonstrated a clear understanding of the provider’s values and strategic goals and were able to explain how these informed their day‑to‑day work and the priorities of their team. These values were also visible across the organisation, being displayed on the provider’s website, on noticeboards within all hubs, and reflected in the service’s statement of purpose.

During our observation of a team meeting, staff were given meaningful opportunities to contribute to discussions about service strategy, particularly in relation to areas undergoing development or change. This supported a culture where staff felt involved in shaping the direction of the service and confident that their views were valued.

Monthly managers’ meetings took place, and outcomes from these were cascaded to staff through monthly team meetings led by team leaders. The ‘Ask Adam’ initiative was introduced to give the staff team an opportunity to influence and shape the service. The senior operations manager held an open forum every other month, which enabled staff to share their views on how the service was operating. Two separate meetings were held—one for the north and one for the south—to ensure staff had more opportunity to speak. Each area of the county had its own ‘Actions’ list, and following every meeting an ‘Ask Adam Newsletter’ was produced and circulated to provide updates.

Leaders took proactive steps to identify and address workforce inequalities, creating an inclusive environment where staff felt respected, supported, and treated fairly. They showed a strong understanding of equality, diversity, and human rights and modelled behaviours aligned with these principles in their interactions with patients, staff, and external partners. This contributed to the provision of equitable, person‑centred care across the service. Staff felt well supported and valued. One team member shared that they had received support to help them manage their hearing impairment in the workplace. This demonstrated a proactive approach to ensuring reasonable adjustments were in place and that staff were supported to carry out their roles effectively.

Staff demonstrated a good understanding of how their individual responsibilities supported the delivery of safe, high‑quality care. They described feeling supported by leaders and confident that their work made a positive difference to patient outcomes. This alignment between strategic vision and frontline practice helped sustain a cohesive, values‑driven culture throughout the service.

Description: We have inclusive leaders at all levels who understand the context in which we deliver care, treatment and support and embody the culture and values of their workforce and organisation. They have the skills, knowledge, experience and credibility to lead effectively and do so with integrity, openness and honesty.

We scored the service as 3. The evidence showed a good standard. The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Leaders demonstrated a strong, detailed understanding of the services they were responsible for and consistently supported their teams to deliver safe, high‑quality, person‑centred care. They were visible and approachable within all areas of the service, making themselves easily accessible to peoples, families and staff. Leaders modelled respectful, inclusive behaviours that aligned with the organisation’s values and helped foster a positive, supportive workplace culture.

Leaders had the appropriate skills, experience and professional knowledge to perform their roles effectively. The service had clear leadership structures in place, ensuring well‑defined lines of accountability. Staff at all levels understood their roles, responsibilities and the wider strategic priorities of the organisation. Leaders demonstrated awareness of emerging issues, operational pressures and risks, and took proactive steps to address these before they impacted the quality or safety of care.

Leaders also took an active approach to identifying and addressing any cultural or workforce issues. They monitored staff morale, encouraged open dialogue and provided support where concerns were raised. Staff felt able to speak openly and that leaders were responsive to their needs.

This leadership approach contributed to a culture of continuous improvement, professional development and shared responsibility. Staff were supported to learn, grow and maintain the delivery of safe, compassionate and high‑quality care.

Description: We have inclusive leaders at all levels who understand the context in which we deliver care, treatment and support and embody the culture and values of their workforce and organisation. They have the skills, knowledge, experience and credibility to lead effectively and do so with integrity, openness and honesty.

We scored the service as 3. The evidence showed a good standard. The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Leaders promoted an open and transparent culture where staff felt safe to raise concerns. Concerns were listened to, acknowledged, investigated, and addressed in a timely and appropriate manner. Individuals who raised issues received regular updates, and outcomes were communicated clearly to support learning and improvement. Staff t felt confident to speak up and understood the whistleblowing procedures in place.

Managers and staff had access to feedback from peoples, carers and colleagues, and used this information to inform service improvements. People were actively involved in discussions about proposed changes to the service, ensuring that developments were shaped by the people who used it.

The service had clear policies and procedures in place to support whistleblowing and Freedom to Speak Up. Information on how to raise concerns was prominently displayed on noticeboards, including posters with a QR code to enable easy access to online reporting. Staff we spoke with demonstrated a good understanding of these processes and felt able to raise concerns without fear of reprisal. LRP had a nominated Freedom to Speak Up lead. The “LRP Connect pages” made it easy for staff to raise concerns or speak up if they had any issues. Over the previous three months, LRP had not received any concerns.

Staff shared that they were encouraged to contribute openly and were given space to raise issues, make suggestions and help drive improvements. This reflected a culture where continuous learning and staff voice were valued and embedded in everyday practice.

Description: We value diversity in our workforce. We work towards an inclusive and fair culture by improving equality and equity for people who work for us.

We scored the service as 3. The evidence showed a good standard. The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Managers implemented appropriate reasonable adjustments to support staff in carrying out their roles effectively. One member of staff had adjustments in place to work alternate shift patterns to support with childcare arrangements. Staff felt well supported, valued by the organisation which in turn made them want to do their best for the organisation.

Staff consistently reported that they were treated fairly and equitably within the service. Both staff and leaders demonstrated a clear understanding of the Equality Act, and we saw evidence of flexible working options and reasonable adjustments being embedded within the provider’s recruitment and selection policy.

Staff had access to equality, diversity and inclusion training, with a compliance rate of 81% at the time of our assessment. We were told that several staff members benefited from inclusion passports related to a wide range of needs, including physical disabilities, neurodiversity, cultural or religious requirements, and menopause-related adjustments.

Management described a comprehensive structure of networks and forums designed to meet the EDI needs of the workforce. These included the Local LRP Equality, Diversity and Inclusion Group, the Ethnically Diverse Community Network, the Autism and Neurodiverse Allies Forum, the Disability Network and the LGBTQ+ Network. In addition, the service held regular spotlight events throughout the year, focusing on areas such as neurodiversity celebration week, religious festivals, and culturally significant events. These events aimed to raise awareness, improve knowledge and understanding, and encourage open discussion across the workforce.

Description: We have clear responsibilities, roles, systems of accountability and good governance to manage and deliver good quality, sustainable care, treatment and support. We act on the best information about risk, performance and outcomes, and we share this securely with others when appropriate.

We scored the service as 3. The evidence showed a good standard. The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

Leaders made effective use of data to monitor service performance and ensure oversight of key quality and safety indicators. A clear governance framework was in place which set out the information that must be discussed at service level, ensuring essential topics—such as learning from incidents, complaints, safeguarding alerts and performance updates—were consistently shared and reviewed.

Monthly team meetings were held, providing a structured forum for cascading important information. Staff routinely discussed patient assessments, emerging risks and operational issues, ensuring teams had up‑to‑date knowledge to support safe and effective care.

Staff had implemented learning and recommendations arising from reviews of deaths, incidents, complaints and safeguarding concerns. They participated in mortality and morbidity meetings, where cases involving deaths were examined in detail. These meetings were focused on identifying learning, agreeing actions, implementing changes to practice where appropriate, and ensuring key information was communicated to the wider staff group.

Clear arrangements were in place for joint working with other teams both within the organisation and externally. Staff understood how to work collaboratively to meet the needs of people, supported by joint working agreements with partner agencies. contract management meetings (CMMs) were held between LRP and the local commissioning team to monitor progress, outcomes, and key performance indicators. As part of the alliance model, these meetings provided an opportunity to discuss areas for improvement and to work collaboratively to unblock pathways and drive service development. The CMM report was used to showcase the innovative and impactful work delivered, supporting a transparent approach. The CMMs summarised and evidenced the breadth of work undertaken by the service.

Local audit activity was well established, supported by a service‑wide audit schedule. Staff had access to the risk register and understood how to escalate concerns. Issues raised by staff reflected those recorded on the register, indicating transparency and alignment between frontline experience and organisational oversight. Identified risks were assigned to responsible individuals and reviewed formally within quarterly local clinical governance meetings.

The service had appropriate business continuity plans in place, outlining how essential functions would be maintained in emergency situations such as severe weather or IT and telephone failures.

Staff had access to the equipment and IT systems required to perform their roles effectively. The IT infrastructure, including the telephone system, functioned reliably and supported timely communication, with remote meetings frequently used to improve access and efficiency. The service adhered to organisational policies relating to confidentiality and information governance. Mandatory training included GDPR and information security, ensuring staff understood their responsibilities for handling information safely.

The service provided monthly data to commissioners covering incidents, performance and financial information. In addition, the service complied with National Drug Treatment Monitoring System (NDTMS) reporting requirements and consistently met submission deadlines.

Description: We understand our duty to collaborate and work in partnership, so our services work seamlessly for people. We share information and learning with partners and collaborate for improvement.

We scored the service as 3. The evidence showed a good standard. The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

Leaders actively engaged with a wide range of external stakeholders, and stakeholders consistently described the provider as collaborative, responsive and solution‑focused. The service worked effectively with partner agencies to support coordinated care and ensure people received the right support at the right time.

People and staff had opportunities to meet directly with members of the senior leadership team to share feedback and discuss areas for improvement. Leaders were visible across service locations, making themselves accessible for face‑to‑face discussions and demonstrating a commitment to open, transparent communication.

Designated safeguarding leads were in post and played an active role in multi‑agency safeguarding arrangements. Their responsibilities included attending external forums such as MARAC (Multi‑Agency Risk Assessment Conferences) to discuss and plan support for individuals at high risk, particularly in the context of domestic abuse. This ensured information was shared appropriately and that people received coordinated protection and support.

The service also contributed positively to the wider community. Staff and leaders participated in local events, such as LGBTQ+ Pride celebrations, helping to promote inclusion and increase visibility of the service. The team engaged with local colleges and universities, offering regular drop‑in sessions and delivering targeted harm‑minimisation advice tailored to substances commonly used by young adults in those settings.

Staff felt there was an open, transparent and collaborative relationship between the service and the people who used it. This inclusive approach helped strengthen community connections and ensured the service remained responsive to local needs.

Description: We focus on continuous learning, innovation and improvement across our organisation and the local system. We encourage creative ways of delivering equality of experience, outcome and quality of life for people. We actively contribute to safe, effective practice and research.

We scored the service as 3. The evidence showed a good standard. The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contribute to safe, effective practice and research.

Staff felt the service genuinely involved people using the service—and where appropriate, their relatives—in shaping developments and evaluating areas for improvement. They described this approach as inclusive and collaborative, supporting a culture where feedback directly contributed to positive change.

During the team meeting we observed, staff were actively encouraged to share ideas related to service improvement and innovation. Leaders facilitated open discussion, welcomed suggestions and created a safe environment where staff felt confident proposing new approaches or highlighting opportunities to improve practice. This demonstrated a strong commitment to continuous learning and reflective teamwork.

LRP completed a quality improvement project to remodel the substance use mental health (SUMH) model. Following audit findings and staff feedback, the model was redesigned to strengthen clinical leadership, streamline referral processes, improve documentation, and enhance support for complex cases. New structures, including complex case meetings, a non‑opiate MDT, and regular “hub huddles,” improved accessibility to specialist advice. The redesigned model was rolled out through staff training and engagement across all hubs, with plans for re‑audit to ensure sustained improvements.

A range of quality assurance systems were in place, and we saw several being actively used to monitor performance and drive service improvement. These included audits, incident reviews, feedback mechanisms and service‑level monitoring tools. Leaders and staff demonstrated how learning from these processes was used to refine practice, implement changes and ensure the service continued to develop in response to emerging needs and evidence.