Lincolnshire Partnership NHS Foundation Trust

Updated 20 August 2026

Lincolnshire Partnership NHS Foundation Trust (LPFT) were established in June 2002 when social care and health services, formally provided by Lincolnshire County Council and Lincolnshire Healthcare NHS Trust were brought together to create a new mental health and learning disabilities service. They were authorised as a foundation trust in October 2007. LPFT provides specialist mental health, learning disability, and social care service, which includes, urgent & Crisis Care, Adult Community Services, Inpatient Care, Older Adults & Frailty and Specialist Services, such as child and young people mental health, eating disorder services learning disability and autism support.

The trust has approximately 200 inpatient beds that support adults of working age, long stay rehabilitation, forensic inpatient or secure wards and wards for older people. The trust employs over 2900 staff and provides services in a variety of settings form over 50 different locations. The trust provides care and treatment to a population of around 813,000 people who are registered with a Lincolnshire GP.

LPFT are part of Better Lives Lincolnshire, the local Integrated Care System (ICS). The trust was placed in segment 3 of the latest NHS Oversight Framework (NOF) segments data from Q3 2025-26, published 18 March 2026. The trust was placed in segment 3 due to its financial position. Without the financial issues the trust have they would have been placed in segment 2.

We undertook a trust level (well-led) assessment of the trust which included an onsite visit between 02-04 June 2026. We also held 15 focus groups on and off site and reviewed virtual board and council of governor’s meetings.

We assessed all 8 of the quality statements in the well-led key question in this assessment.

Since June 2025, we have undertaken a programme of assessments following the Single Assessment Framework (SAF). In total, 5 assessments were completed, covering 5 different Assessment Service Groups (ASG’s) between June 2025 and June 2026. The well led review followed assessments of 5 of the trust frontline mental health services (assessment service groups – ASG’s) wards for older people with mental health problems, acute wards for adults of working age and psychiatric intensive care units, forensic inpatient wards, long stay or rehabilitation mental health wards for working age adults.

We assessed long stay or rehabilitation mental health wards and acute wards for adults of working age due to concerns about patient safety, staff competencies in managing physical health and staff competencies in the legal and clinical requirements for rapid tranquilisation. We took enforcement action against the trust for them to improve in these areas. Prior to the well led review we returned to acute wards for adults of working age and found the trust had taken the required action and were no longer in breach of the Health and Social Care Act regulation 12.

We assessed wards for older people with mental health problems and forensic inpatient wards as they had not been assessed since 2017. We found no concerns and both ASG were rated as good.

All 5 ASGs were assessed against all quality statements within the Single Assessment Framework. This resulted in the re rating of the ASG and we found improvements in the ratings of 1 ASG, 3 had remained the same and 1 had deteriorated.

This trust wide well-led review was carried out to assess how ‘well-led’ the trust was following the programme of assessments of frontline services. The trust was rated as good and we found no breaches of regulations.

We found the trust demonstrated a clear and well-established vision, strategy, and values focused on supporting people to live well in their communities. Leadership and governance were strong, with staff engaged and understanding their roles in delivering objectives. A positive, open culture was evident, where staff felt confident to speak up and contributed to improvement.

Leaders were visible and promoted inclusive behaviours, supporting workforce wellbeing and development. Governance arrangements provided clear accountability and effective risk management, though challenges remained around workforce capacity and financial pressures.

Partnership working was effective, supporting integrated, person-centred care and innovation. While quality improvement and digital initiatives progressed, these were not yet fully embedded across all services.

Updated 22 June 2026

Lincolnshire Partnership NHS Foundation Trust, Community Mental Health Teams (CMHT) provided community services for adults with a learning disability and/or autistic people, including those with complex mental health needs.

The service comprised a single point of access (SPA) for all referrals, four community learning disability hubs staffed by multidisciplinary teams, an autism diagnostic service, and a countywide enhanced support liaison service (ESLS). These services operated across Lincolnshire, delivering support to people within their local communities.

As part of this assessment, we visited three community learning disability hubs across various locations, this included the enhanced support and liaison service (ESLS) based in Lincoln and the autism diagnostic service, based in Sleaford. Data and evidence was reviewed for all locations as part of our off site assessment.

We assessed all 33 quality statements across the five key questions of Safe, Effective, Caring, Responsive, and Well-led. The service was last inspected in October and November 2018, when it was rated Good. Following this assessment, the overall rating has remained Good.

Staff delivered care and treatment consistently in line with national guidance and recognised best practice, supporting people to achieve positive and sustainable outcomes. Individuals had access to a wide range of specialist interventions tailored to their assessed needs. Staff received appropriate training, regular supervision, and annual appraisals, enabling them to deliver high-quality and innovative care. The multidisciplinary team worked collaboratively and maintained effective partnerships with external agencies and professionals to ensure continuity of care and positive outcomes.

People were treated with kindness, dignity, and respect. Staff actively promoted choice, independence, and person-centred care, ensuring individuals were involved in decisions about their care, treatment, and support. People felt listened to and supported to understand their rights and maintain control over their lives and wellbeing.

Leaders were visible, approachable, and provided effective support to staff. They promoted a positive culture characterised by openness, learning, collaboration, and continuous improvement, enabling the service to develop and respond to the needs of the people it supported.

We assessed the service against the principles of Right Support, Right Care, Right Culture to determine whether people with a learning disability and autistic people were supported to experience respect, equality, dignity, choice, independence, and inclusion in their daily lives.

 

Mental Health Act and Mental Capacity Act Compliance

During this assessment, we reviewed how the service complied with the Mental Health Act (MHA) and Mental Capacity Act (MCA) and how people’s rights were protected in practice.

Staff demonstrated a good understanding of the MHA and the accompanying Code of Practice. They applied the legislation appropriately when supporting people who were subject to the Act, ensuring care and treatment was delivered lawfully and that people’s rights were upheld. There were effective governance arrangements in place to oversee the use of the MHA, including clear reporting structures, regular reviews, and monitoring processes. Where required, people had access to independent mental health advocates (IMHAs) and second opinion appointed doctors (SOADs), providing additional safeguards and support. We found no evidence of inappropriate or excessive use of restrictive interventions. Staff and leaders promoted a least restrictive approach and sought to involve people in decisions about their care and treatment wherever possible.

Staff demonstrated a good understanding of the MCA and its principles. Capacity assessments were decision-specific and completed in accordance with the two-stage test. Assessments and decision-making processes were clearly documented within care records. Where people lacked the capacity to make a particular decision, staff followed best-interest decision-making processes and involved the relevant professionals, family members, carers, and advocates. Records showed the rationale for decisions, alternative options considered, and who had been consulted during the process.

Staff made reasonable adjustments to support people to understand information and participate in decisions about their care. These included the use of easy-read documents, adapted communication methods, and specialist support from speech and language therapists where necessary. Governance systems provided effective oversight of MCA practice through regular audits and review of capacity assessments and best-interest decisions. Staff received ongoing training and support in relation to the MCA, human rights, and equality legislation, helping to ensure that care and treatment was delivered in a way that respected people’s rights, dignity, and autonomy.

People’s experience

We spoke with 3 people who used the service and 4 relatives/carers. Feedback about the service was consistently positive, with people expressing satisfaction with the quality of care and treatment they received.

People felt safe, supported and well cared for. Staff were consistently described as kind, compassionate, approachable and respectful. People said staff were attentive to their individual needs and delivered care in a way that promoted dignity and respect. They felt listened to, involved in decisions about their care, and valued throughout their treatment journey.

People and their relatives told us that staff were accessible and responsive. Staff were described as proactive in providing support, taking time to listen, and responding promptly to needs. Relatives reported that communication was effective, with regular updates provided regarding their loved one’s progress, care and treatment. They also felt that staff recognised and responded appropriately to both physical and mental health needs, giving equal importance to each.

People, and where appropriate their families, were actively involved in developing care and risk management plans. This collaborative approach helped to ensure care remained person-centred and was tailored to individual needs, preferences and circumstances.

People spoke positively about the range of therapeutic activities available. These were reported to be well attended and contributed to engagement, recovery and inclusion. People told us that participation in these activities provided structure and meaningful opportunities that supported their physical, emotional and mental wellbeing, and aided their recovery and rehabilitation.

People were aware of how to raise concerns, provide feedback or make a complaint. They told us they felt listened to and felt confident that their views would be taken seriously, which empowered them to share their experiences and opinions about the service.

Updated 21 May 2026

Lincolnshire Partnership Foundation Trust Older Adult Community Mental Health Teams (OA CMHTs) provide a comprehensive, multidisciplinary service delivering assessment, treatment and recovery-focused support to older people with complex mental health needs, including those experiencing dementia and associated behaviours that challenge. The service operates across multiple localities and offers care within patients own homes and communities, promoting independence and enabling individuals to remain in familiar environments wherever possible.

Teams are made up of a range of skilled professionals, including community psychiatric nurses, occupational therapists, consultant psychiatrists, support workers and administrative staff. They have direct access to specialist services such as older adult psychology, social care and neighbourhood teams, which supports timely, coordinated and holistic care delivery. This multidisciplinary approach ensures that patients received personalised care tailored to their mental health, physical health and social needs.

The service works collaboratively with a wide network of partner organisations, including primary care, social services, continuing healthcare providers and voluntary sector organisations. OA CMHTs are embedded within locality-based multi-agency Neighbourhood Teams, enabling seamless access to wider support for patients with complex and interrelated needs such as frailty, falls risk and long-term conditions. This integrated model supports joined-up care, reduces fragmentation and improves outcomes for people using the service.

As part of this assessment, we carried out onsite visits to four locations: Lincoln (Witham Court), Skegness (Holly Lodge), Louth (Windsor House), and Boston (Pilgrim Hospital). During these visits, we spoke with staff and reviewed care processes to understand how services were delivered in practice.

For the offsite element of the assessment, we requested and reviewed evidence and data from all seven localities within the service. This included the additional teams based at Spalding (Johnson Hospital), Sleaford and Grantham (Sycamore Centre), and Stamford (Stamford Resource Centre). This approach enabled us to take a comprehensive view of performance, governance and care delivery across the whole service.

Care is delivered during weekdays (9am–5pm) with clear pathways for escalation and partnership working to ensure patients can access additional support when needed. This included sign posting patients and carers to pharmacies, GP surgeries, The Samaritans and the crisis team. Staff demonstrated a strong understanding of person-centred and recovery-focused care and worked collaboratively with individuals, families and carers to support wellbeing and independence.

Leadership across the service was consistent, with clear management structures in place at each locality. Team leaders were identified and accessible, supporting effective oversight and coordination of care delivery across sites. Staff reported positive working relationships within teams and with leaders, contributing to a supportive and inclusive culture.

The service was previously rated good by the Care Quality Commission (published June 2017) under the former inspection framework. This assessment was conducted under the CQC’s new Single Assessment Framework (SAF) during an unannounced visit, where all quality statements across the five key questions were reviewed. Based on the findings of this assessment, the service has been rated good overall, reflecting consistent delivery of safe, effective, caring, responsive and well-led care.

As part of our offsite assessment, we spoke with five family members via telephone of people receiving support from the Lincolnshire Community Mental Health Team (CMHT). Feedback was consistently positive regarding the care and treatment provided by the service.

Family members told us their relatives felt safe, supported and well cared for by staff. Staff were described as kind, compassionate, approachable and committed to providing high-quality care. Family members said staff treated patients as well as carers with dignity and respect, listened to their concerns and ensured they felt valued and involved in decisions about their care.

Family members reported that staff were accessible and responsive, through scheduled appointments, telephone contact and home visits. They felt patients using the service were able to contact the team when required and that staff responded appropriately and in a timely manner. Feedback also highlighted that staff adopted a holistic approach, taking account of both mental and physical health needs when planning and delivering care.

Family members and their relatives were actively involved in the development of their care and risk management plans. They felt staff sought and considered patients views, wishes and preferences, supporting a personalised and recovery-focused approach to care that reflected individual needs and goals.

Family members also described how patients were supported to engage in meaningful activities within their local communities, such as wellbeing groups, social opportunities and support with daily living skills. They said this provided structure, promoted wellbeing and contributed positively to recovery.

Family members were aware of how to provide feedback, raise concerns or make a complaint. They felt confident in doing so and reported that staff listened and responded appropriately when issues were raised.

Mental Health Act and Mental Capacity Act Compliance Summary.

Most staff had completed relevant Mental Health Act (MHA) training. At the time of our assessment compliance levels all locations ranged from 70% to some locations being 100% compliant. Although some services had lower levels of compliance than the trust expected we found that staff demonstrated a good understanding of the Act, associated guidance and their responsibilities within a community setting. Staff were aware of how the MHA applies in the community, including the use of Community Treatment Orders (CTOs), recall processes and least restrictive practice. They had access to appropriate administrative support and legal advice, including Mental Health Act administrators, and were clear about how to seek guidance when required.

Policies and procedures relating to the MHA, including the Code of Practice, were readily accessible to staff. Information about Independent Mental Health Advocacy (IMHA) services was available, and staff understood how to refer patients to advocacy services to support their rights and involvement in care and treatment.

Staff explained patients’ rights under the MHA in a clear and accessible way, particularly for those subject to Community Treatment Orders or other legal frameworks. These discussions were documented appropriately and revisited as needed to ensure understanding. Staff demonstrated a commitment to least restrictive practice and supported patients to remain in the community wherever safe and appropriate.

Where required, staff liaised with relevant professionals, including Approved Mental Health Professionals (AMHPs) and Second Opinion Appointed Doctors (SOADs), to ensure legal requirements were met. Documentation relating to MHA processes was managed securely and was accessible to authorised staff through community-based systems.

Regular audits of MHA practice were undertaken across the service, demonstrating good levels of compliance. Findings from audits were used to inform learning, improve practice and strengthen governance arrangements.

Compliance with Mental Capacity Act (MCA) training was high, and staff demonstrated a good understanding of the five statutory principles. They were able to apply these effectively when working with patients in the community, particularly where there were concerns about decision-making capacity.

The service maintained up-to-date policies covering the MCA and Deprivation of Liberty Safeguards (DoLS), and staff were aware of how these apply in community settings, including the interface with the Liberty Protection Safeguards (LPS) where relevant. Staff knew how to access advice and support when managing complex capacity or safeguarding issues.

Staff took all practicable steps to support patients to make their own decisions and promote autonomy. Where concerns about capacity arose, decision-specific assessments were completed appropriately and clearly documented. When patients lacked capacity, best interest decision-making processes were followed, involving relevant professionals, carers and family members where appropriate, and considering the person’s wishes, feelings, values and cultural background.

Systems were in place to monitor compliance with the MCA and associated safeguards. This supported consistent, lawful and person-centred practice across community mental health teams and ensured that patients rights were upheld.

Updated 12 March 2026

Lincolnshire Partnership Foundation Trust provide wards for older people with mental health problems for people in Lincolnshire at Witham court, incorporating Brant and Langworth wards.

Brant ward (adults any age with diagnosis) is purpose built 18-bed inpatient unit for older adults with functional mental health needs, such as depression or schizophrenia. The ward is a mixed-sex unit, with all bedrooms offering single occupancy and en-suite bathrooms. This ward was never inspected before.

Langworth ward is an 18-bed assessment and treatment unit for both men and women with acute organic illnesses, such as dementia, who require inpatient care. The unit is divided into male and female wards, each offering single-sex accommodation and a shared lounge area. The service was last rated as Good published June 2017. The report was published following Care Quality Commission’s (CQC) old inspection approach using key lines of enquiry (KLOEs), prompts and ratings characteristics.

This assessment has been completed following CQC new approach to assessment; Single Assessment Framework (SAF). This was an unannounced assessment, which means the provider was not told an assessment was going to be taking place beforehand. During this assessment we looked at all quality statements across all 5 key questions. As we assessed all quality statements at this visit the current rating reflects the findings from this assessment. We rated this service as good.

People’s experience.

We spoke with eight patients across both wards. Patients were positive about the quality of care and treatment they received. They reported feeling safe, supported, and well cared for by staff, who were consistently described as kind, compassionate, and approachable. Patients said staff were attentive to their needs and engaged with them in a respectful and dignified manner, helping them feel heard and valued throughout their care and treatment.

Patients felt staff were visible, accessible, and responsive, offering support, listening attentively, and responding in a timely and appropriate way. They also felt that staff gave equal priority to both physical and mental health needs.

Patients were involved in the development of their care and risk management plans. This collaborative approach supported person-centred care, with treatment tailored to individual needs, preferences, and circumstances.

The service provided a range of regular therapeutic activities, which were well attended and encouraged patient engagement and inclusion. Patients said these activities offered meaningful structure to their day and had a positive impact on their physical, mental, and emotional wellbeing.

Patients were supported to raise concerns, make complaints, and provide feedback. They felt listened to and empowered to share their views. Patients also reported that the food provided was of good quality, with a variety of options available to meet individual preferences, as well as religious, cultural, and dietary requirements.

Mental Health Act and Mental Capacity Act Compliance Summary

Most staff had completed Mental Health Act (MHA) training at Levels 1 and 2 and demonstrated a strong understanding of the Act and its requirements. Staff had access to appropriate administrative support and legal advice regarding the application of the MHA and the Code of Practice and were clear about who their Mental Health Act Administrators were.

Local MHA policies and procedures, along with the Code of Practice, were readily accessible. Information about Independent Mental Health Advocacy (IMHA) services was also clearly available to people using the service.

Staff consistently explained patients’ rights under the MHA in a clear and accessible manner, repeating information when necessary and documenting these discussions appropriately. Patients were supported to take Section 17 leave when authorised, with processes in place to ensure this was facilitated safely and without delay.

Where required, staff sought input from a Second Opinion Appointed Doctor (SOAD). Detention paperwork and associated documents, including Section 17 leave forms, were stored securely and were accessible to relevant staff.

Regular audits of MHA practice were undertaken, demonstrating good levels of compliance. There was clear evidence that learning and improvement actions were implemented in response to audit findings.

Compliance with Mental Capacity Act (MCA) training was high, with 93% of staff having completed the training. Staff showed a good understanding of the MCA, particularly the five statutory principles, and were able to apply these in practice. The provider maintained an up-to-date MCA and Deprivation of Liberty Safeguards (DoLS) policy. Staff were aware of this policy, could easily access it, and knew how to obtain further advice regarding MCA and DoLS where needed.

Staff took all reasonable steps to support individuals to make their own decisions. Where there were concerns about a person’s capacity, assessments were carried out and recorded appropriately on a decision-specific basis, with a clear rationale documented.

When individuals lacked capacity, best interest decision-making processes were followed appropriately. Staff involved relevant professionals and relatives, taking into account the individual’s wishes, feelings, cultural background, and personal history. The service had effective systems in place to monitor compliance with the MCA, supporting consistent and lawful practice.

Updated 3 March 2026

We assessed Lincolnshire Partnership NHS Foundation Trust, assessment service group (ASG): Acute wards for adults of working age and psychiatric intensive care units from 21 to 22 April 2026. We assessed all 33 quality statements.
We assessed this service to review the progress made against the warning notice that wwas served on the provider following the inspection in June 2025. We rated the service as good. The service had made improvements and is no longer in breach of regulations 11 (Consent), 12 (Safety), and 17 (Governance).

We visited the following wards as part of the assessment:
Ellis and Castle wards within The Peter Hodgkinson Centre at Lincoln County Hospital. These are adult inpatient wards which helped people on their recovery journey. Ellis is a 20-bed male ward and Castle is a 20-bed female ward.
Ash Villa Sleaford, 15-bed acute treatment ward for females.
Havenside, a new 19 bed mixed sex unit at Norton Lea, in Boston. This unit has replaced Ward 12 at Pilgrim Hospital.
The Hartsholme Centre in Lincoln, a 10 bedded all male psychiatric intensive care service (PICU) for people with acute mental health difficulties.
Staff now considered, assessed, and recorded patient’s consent to care and treatment. Staff complied with the Mental Health Act Code of Practice when restraint was used and when rapid tranquilisation was administered. The provider’s governance processed and oversight of rapid tranquilisation administration and restrain had now improved.

Leaders embedded a culture of openness and collaboration. Patients were protected from bullying, harassment, avoidable harm, neglect, abuse, and discrimination. Their liberty and best interests were protected in line with legislation.

Staff placed patients at the centre of their care. Patients were treated with kindness, empathy, and compassion. Staff made effort to take patients’ wishes into account and respected their choices to achieve the best possible outcomes for them including supporting people to live as independently as possible. Patients were actively involved in planning care that met their needs. Care, support and treatment were accessible, including physical access. People could access care in ways that met their personal circumstances and protected equality characteristics.

Leaders proactively supported staff and collaborated with partners to deliver care that was safe, compassionate, and integrated. Leaders were focused on implementing improvements. However, governance and management systems to ensure that information about risks, performance and outcomes were still not fully effective. As a result, we found gaps in how patients’ privacy was protected including personalisation of care plans. Gaps remained in mandatory training compliance across key areas.
Mental Health Act and Mental Capacity Act Compliance Summary
Whilst staff demonstrated good awareness of the Mental Health Act (MHA), the level of compliance with MHA training was lower than expected. MHA training compliance was lower than other role essential training modules, with Level 1 at 66.1% and Level 2 at 72.6%. This level of compliance meant that a significant proportion of staff had not completed the statutory MHA training. This was required to ensure the understanding of legal frameworks, detention processes, and patient rights as set out in the Mental Health Act 1983 Code of Practice and Care Quality Commission expectations for safe staffing.
Leaders outlined that they had implemented a targeted improvement programme to strengthen MHA training compliance. This was supported by governance oversight, senior leadership scrutiny, and monitoring through established quality assurance structures. While appropriate governance arrangements and oversight mechanisms were in place, current completion rates meant that measures have not yet fully translated into consistent improvement in training uptake.
However, staff upheld patients’ rights under the Mental Health Act 1983. They completed detention paperwork accurately, ensuring informal patients were not subject to unnecessary restrictions, and explained patients’ rights clearly.
Staff compliance with the Mental Capacity Act (MCA) training was good and in accordance with trust policy and targets. Policies and procedures reflected current guidance, and patients were able to access independent advocacy.
Following issues identified at the previous inspection, leaders had implemented changes aimed at improving practice, including strengthened governance around rapid tranquilisation (RT), improved awareness of Mental Health Act legal requirements, and enhanced monitoring systems.

Updated 23 January 2026

We assessed Francis Willis Unit on the 10 February 2026.

Located in Lincoln, Francis Willis Unit is a low secure forensic unit for males with mental health conditions who present with high risk or challenging behaviours. It offers support to those who are detained under the Mental Health Act (MHA).

The service provides care and treatment up to 15 males. Staff support patients to decrease their levels of behaviours that challenge by providing continuing care, with a focus on community reintegration and preparing the person to move further along the care pathway, or to community living.

The secure services offer comprehensive support to people with complex mental health needs. The service provision is modelled on the NHS secure service specification for medium and low secure services, ensuring patients are given the highest quality of care to enable quick and smooth transitions into local services, wherever possible. The service aims to deliver clinically effective, evidence-based treatment programmes for individuals who require secure care, providing both psychological and physical security.

The service was last rated as Good (published June 2017). This was an unannounced assessment, which means the provider was not told an assessment was going to be taking place beforehand. During this assessment, we looked at all quality statements across all 5 key questions. The current rating reflects the findings from this assessment. We rated this service as Good.

Mental Health Act and Mental Capacity Act Compliance Summary

Most staff had completed Mental Health Act training at Levels 1 and 2, and staff demonstrated a strong understanding of the MHA and its requirements. Staff had access to administrative support and legal advice regarding the application of the Act and the Code of Practice, and they were clear about who their Mental Health Act Administrators were.

Local Mental Health Act policies and procedures, as well as the Code of Practice, were readily accessible to staff. Information about Independent Mental Health Advocacy (IMHA) services was also easily available to people using the service.

Staff consistently explained patients’ rights under the MHA in a way that individuals could understand, repeating this information as required, and documenting the discussions appropriately. Staff ensured that patients were able to take Section 17 leave when authorised, and processes were in place to support safe and timely facilitation of this.

Where required, staff sought opinions from a Second Opinion Appointed Doctor (SOAD). Detention papers and associated documents, such as Section 17 leave forms, were stored securely and appropriately, ensuring they were accessible to relevant staff.

Regular audits of Mental Health Act practice were undertaken. These audits demonstrated good compliance, and there was clear evidence of learning and improvement actions being taken in response to audit findings.

Compliance with Mental Capacity Act training was strong, with 93% of staff having completed MCA training. Staff demonstrated a good understanding of the MCA, particularly the five statutory principles, and were able to describe how these informed their practice.

The provider had an up‑to‑date Mental Capacity Act and Deprivation of Liberty Safeguards (DoLS) policy. Staff were aware of this and able to access it easily. They also knew how to obtain advice relating to the MCA and DoLS from within the service.

Staff took all reasonable steps to support individuals to make their own decisions. Where a person’s capacity was in question, staff carried out and documented capacity assessments appropriately and on a decision‑specific basis. These assessments focused on significant decisions and demonstrated a clear rationale.

When individuals lacked capacity, decision‑making processes were completed in line with best‑interest principles. Staff and relatives were involved appropriately, and there was clear consideration of the person’s wishes, feelings, cultural background, and personal history.

The service had reliable arrangements in place to monitor compliance with the MCA, helping to ensure consistent and lawful practice.

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 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 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.