Lincolnshire Partnership NHS Foundation Trust

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• 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 our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed . The service was in breach of legal regulation in relation to safe care and treatment and consent to treatment . We found that the service did not provide care that was consistently safe or protect people from avoidable harm. We found that the trust had not ensured there were enough staff with the knowledge and training needed to meet the legal requirements for obtaining consent when using rapid tranquilisation under the Mental Health Act 1983. Staff we spoke with were not aware of their legal responsibilities, including the duty of candour to inform patients when this treatment had been given outside the proper legal framework. Because these safeguards were not followed, patients were at risk of receiving medication against their fundamental human rights. We found that the service did not have an embedded learning culture. Staff were not aware of recommendations and actions required following serious incidents. Care plans and risk assessments did not accurately reflect the patient’s risks. Governance systems failed to allow full oversight at board level of the risk to patients who were not kept safe from avoidable abuse or harm.

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Prior to the assessment we were informed of a recent serious incident in relation to rapid tranquilisation. Senior leaders assured us that learning following the incident would be shared with ward managers and their staff. Whilst managers were aware of the incidents not all ward staff were. This was despite senior leaders sharing a pharmacy bulletin including learning from the incident and findings from the rapid tranquilisation audits with all staff.

Staff we spoke with said they had informal debriefs after there had been an incident on the ward and that the staff were supportive of each other. The electronic incident reporting system allowed for debriefs to be requested. However, staff informed us that the official trust debrief can take weeks to organise and sometimes staff were not able to attend if it was on a non-working day. Senior leaders adhered to good practice guidance to undertake the formal debrief between day 3 and day 10 following an incident. However, they did acknowledge that the debriefs were sometimes held outside of these parameters due to staffs’ working patterns, days off and annual leave.

Leaders told us the review process post-incident was thorough, and that learning was shared at the divisional band 7 meetings which were held face to face. There was a daily safety huddle in which all incidents in the previous 24 hours were discussed and learning shared. Incidents and clinical risks were also discussed at the daily handover meetings.

We were also told about a recent development day and that this was a positive learning experience.

It was clear that leaders need to ensure that tools used to communicate lessons learnt following incidents and formal debriefings for staff needed to be more robust and effectively managed to support and develop a positive learning culture and continuous improvement within the service.

We reviewed 12 care records. While risk assessments were updated regularly, they did not consistently reflect the current risks described in the progress notes. For example, one individual was suspected to have brought illicit substances onto the ward and to be involved in drug-related activities outside the hospital. However, their risk assessment did not include a risk management plan addressing this concern. This omission meant staff did not have clear guidance on how to manage the identified risks, increasing the likelihood of harm to both the patients and others on the ward.

Staff told us that therapeutic observations of patients were undertaken at fixed intervals of 15 and 30 minutes and recorded electronically. Patients we spoke with said observations were completed at regular, predictable intervals, one patient said that they were easily able to predict when staff would check on them and this meant they were able to plan self-harm during the regular gaps. However, when we reviewed the general observations data, collated from the electronic observation system we found that staff did compete observations at random times. In doing this is reduces the risk that patient could determine when staff would observe them and harm themselves during the allocated observation times.

We observed posters on the wards clearly listing restricted items, which were visible to staff, patients and visitors and helped to promote awareness of ward safety protocols. Staff recorded a clear admission process. Each admission included a nursing assessment, which was recorded on the electronic patient record system, and every patient was reviewed on admission by a ward doctor. Defined care pathways were in place to guide treatment, dependent on patients’ individual needs. Staff informed us that patients were provided with a copy of their care plan, and we saw that patients could access their care plans on a touchscreen TV in their bedrooms. Staff also reported that they aimed to de-escalate situations verbally before using physical restraint and that the wards had access to safety pods, de-escalation rooms, long-term segregation areas and seclusion rooms and we saw that patients could access their care plans on a touchscreen TV in their bedrooms. Staff also reported that they aimed to de-escalate situations verbally before using physical restraint and that the wards had access to safety pods, de-escalation rooms, long-term segregation areas, and seclusion rooms.

Staff demonstrated awareness of safeguarding processes and compliance with mandatory training, and safeguarding. Staff told us that safeguarding concerns were discussed in daily morning meetings. The trust’s safeguarding team was described as visible and accessible, and posters displayed on the ward promoted awareness of safeguarding principles.

Following the multiple incidents involving the use of rapid tranquilisation without the legal safeguards on the place, the trust referred all the incidents to the local authority and commissioners for review. The outcome of this determined that whilst staff had acted to administer the necessary, proportionate and clinically indicated treatment they had failed to complete legal documentation. It is important to note that this review identified, no significant harm, abuse, neglect or improper treatment had been carried out.

We reviewed 12 patient records and found risk assessments did not consistently involve people in identifying their own triggers, warning signs, or preferred strategies for managing distress. While some records contained quotes from individuals expressing their thoughts and feelings regarding their care plan, this information was not always translated into preferred approaches for staff to take to minimise the use of physical intervention within the risk management plans. We saw regular one-to-one sessions with patients and their named nurse took place, which provided opportunities for collaborative risk discussion, but these sessions were not integrated into care planning or risk assessments. Care plans did not always clearly reflect the risks identified for that individual, which may have limited the ability of staff to respond in a person-centred way during periods of heightened risk. As a result, staff often lacked clear, person-centred guidance on how to reduce anxiety or prevent situations from escalating, increasing the likelihood that interventions such as restraint might be used before less restrictive interventions had been tried. For example, 1 patient who had frequently experienced physical restraint did not have a person-centred care plan in place to ensure that their care was informed by the principles of least restrictive practice and reducing the need for restraint. We saw 16 episodes of restraint lasting 20 minutes or longer during May and June 2025. Rapid tranquilisation had been administered in all 16 cases without the required level of consent to treatment being present.
We spoke with 8 patients on Castle and Ellis ward - 7 said they felt safe and supported to understand and manage risks and 3 patients said the ward corridors felt spacious and allowed them to maintain a safe distance from others, contributing to their sense of safety. However, 1 patient said they had raised concerns about the atmosphere and how conflict was handled by staff and said the “ward was scary at times”.
 

On Ward 12, there were environmental blind spots which had been partially mitigated with mirrors. The ward used an airlock-style entrance and had alarm and nurse call systems in place. CCTV was available and used for post-incident review. Sleeping areas were gender-segregated, and women did not need to pass male rooms to access bathroom facilities. Separate lounges were provided for male and female patients. Ligature kits were easily accessible and routinely maintained to ensure they worked when needed. Room searches were conducted on an individual basis when required, for example when there were concerns that a patient had bought illicit substances onto the ward. Patient lockers included charging points for mobile phones. Environmental checks (inspections of the physical ward environment to identify and mitigate risks) were completed by staff every 30 minutes. The layout on Ward 12 included large dormitory sleeping areas with only a small number of individual bedrooms, which did not have ensuite bathrooms. Although a move to a new facility is planned for 2026, the current use of dormitories limits privacy and can increase the potential for disturbance or conflict between patients. This met the care quality commissions guidance on the elimination of dormitory accommodation.
On Castle and Ellis wards, we found that the ward environment was very noisy, particularly when alarms were activated either locally or from nearby wards, this occurred multiple times whilst we were on the wards. Patients told us that this could be very distressing, and the acoustics of the ward appeared to amplify the sound. Staff acknowledged that noise levels could be challenging. We were informed that acoustic panels had been installed to reduce the impact, but noise remained a concern at times. The noise and overstimulation may impact patients’ wellbeing, increase agitation, or reduce the therapeutic value of the ward environment, particularly for individuals who are noise-sensitive or in heightened emotional states.
The seclusion room on Ward 12 allowed for clear observation and had a window on the top and bottom of the door which meant that staff could observe patients who were standing or sitting. On Castle and Ellis ward, the seclusion rooms allowed for clear observation and two-way communication. There was an area designed to be used for long-term segregation which had access to an outdoor space and access to the enhanced care bedroom corridor.
 

On each of the wards we visited, we found that there was a nurse allocated to attend ward rounds. Staff told us this individual was protected from being pulled back into direct care numbers, allowing them to focus solely on the ward round.

On each of the wards we visited, we found that patients had regular one to one sessions with the staff.

Staff told us that short-notice sickness and increased acuity could occasionally make staffing more difficult, but staffing was not generally a concern. We were told that agency staff were rarely used and bank staff who worked on the wards knew the patients and service well.

On each of the wards we visited, we found that there was a nurse allocated to attend ward rounds. Staff told us this individual was protected from being pulled back into direct care numbers, allowing them to focus solely on the ward round.
On each of the wards we visited, we found that patients had regular one to one sessions with the staff.
Staff told us that short-notice sickness and increased acuity could occasionally make staffing more difficult, but staffing was not generally a concern. We were told that agency staff were rarely used and bank staff who worked on the wards knew the patients and service well.
Patients we spoke to said there was nearly always a staff member available to talk to, they said leave was rarely cancelled due to a lack of staff and there was always a designated ‘visible nurse’ role on duty.
Staff told us that they always had enough daytime and night time medical cover, and a doctor was always available to assist the ward in an emergency.
Staff we spoke with on ward 12 said their service would benefit from the introduction of a dedicated discharge liaison role, to ensure patients were discharged safely and in a timely manner.

The trust had not ensured there were enough staff with the necessary training and legal knowledge to safely manage rapid tranquilisation. This included the Mental Health Act (MHA) 1983 requirements for obtaining consent or authorisation before administering sedating medication in an emergency. This gap in competence meant that patients were at risk of receiving powerful sedative medicines outside the legal framework, placing them at risk of serious physical side-effects, and breaching their legal rights.When we returned to the ward on 01 July 2025, we found that the trust had taken action to address this and all staff had been trained reducing the risk to patients.

On Ellis and Castle, the ward environment was clean and tidy. Décor was well maintained, and furniture was in good condition.

We found clinic rooms within the service were clean, tidy, and well organised. Medication fridges were checked regularly, and controlled drugs and other medicines were stored securely in line with legal and regulatory requirements. We also found there was information available for patients to read about their medicines. Whilst day-to-day storage and record-keeping of medicines were well managed, we found breaches in the safe administration of sedative drugs, highlighting that the provider failed to sure medicines were always used safely, effectively, or lawfully.

Initially we found 32 episodes, later confirmed by the trust to be 26 episodes, whereby patients received rapid tranquilisation, an emergency injection of a sedating medication used to calm someone who is highly agitated or at risk of harming themselves or others, without the legally required level of consent or authorisation. We acknowledge that the medications that were administered as they were clinically indicated to support the patient’s mental health and reduce associated risks. This means that sedation was administered without the necessary checks to confirm the patient’s agreement, or where consent was not possible, without the proper safeguards to protect their human rights. Under the Mental Health Act 1983, patients who are detained must have appropriate legal authorisation in place before they can be given medication for a mental health condition after the first three months of detention. This is recorded on either a T2 form (where the patient has capacity and consents to the treatment) or a T3 form (where the patient does not have capacity or refuses treatment, and an independent Second Opinion Appointed Doctor [SOAD] authorises it). In these 26 cases, rapid tranquilisation was given without a valid T2 or T3 certificate in place, meaning treatment was administered without the required legal authority.