Lincolnshire Partnership NHS Foundation Trust

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• 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 rating: Inadequate.

We found that governance systems failed to identify or escalate serious legal breaches in the use of rapid tranquilisation.

Governance arrangements were not robust enough to provide the board with clear oversight of the risks to patients.

This lack of leadership and accountability left patients exposed to avoidable harm and breaches of their legal rights and demonstrated that the trust did not have the systems or culture required to keep people safe.

This service scored 46 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The trust had a clear vision, strategy and values which were co-produced with service users, governors, staff, stakeholders and carers. Although staff did not apply these consistently.

Although the trust had systems, processes, and procedure to monitor the service, they were not always applied quickly or robustly to identify areas of risk or non-compliance with legal frameworks and support positive changes in people’s care.

When we revisited the service on 01 July it was evidence that action had been taken to address the concerns we found. Staff reported the senior leaders had feedback our initial concerns with in a clear and kind way so that staff understood and could make positive changes in their practice to improve patient care.

Prior to the assessment the trusts leaders failed respond to swiftly or robustly or have oversight to identify and take timely actions in relation the application of the Mental Health Act. They had identified concerns relating to the mental Health act and rapid tranquilisation but did not act immediately to address them and safeguard patients. It was only when we raised the concerns that action was taken.

We were pleased when we returned to the service on the 01 July 2025 and found that the trust had taken immediate actions to address the concerns we raised. In doing this they also ensured that local leaders had the skills, knowledge, experience and credibility to lead effectively. Training records, regular audits and clear feedback developed the working relationships with senior leaders and ward staff.

Although we found during the initial assessment of this service a lack of consistent and clear leadership which was impacting on patient care. This had been resolved when we returned on 01 July 2025.Staff felt that senior leaders delivered difficult messages in a clear but supportive way, with action plans that staff could implement to improve patient care.

The trust had a Freedom to Speak Up (FTSU) policy and we saw posters on the wards explaining how staff could contact the Freedom to Speak Up Guardian. These structures provide clear routes for raising concerns. FTSU champions work within the adult inpatient wards and are represented in staff networks that represent protected characteristics. In addition, 87% of staff had completed training in ‘speaking up’.

One member of staff told us about a positive experience of using the freedom to speak up procedure. However, some staff told us they were reluctant to speak up previously because they feared negative consequences for their career. This had now changed which was positive.

Data provided by the trust, for acute services shows that since Q2 in 2022 there has been a year on year an increased number of staff raising concerns to the FTSU guardian from 29 to 44 in Q2 of 2025.

Senior leaders, we spoke with said the trust valued diversity in the workforce and were clear that work was still on going to make further improvements. They said there were several forums which focused on inclusivity and fair culture by improving equality and equity for people working in the trust. For example, staff Networks with executive sponsorship (Race Ethnicity and Cultural Heritage, MAPLE- Mental and Physical Health Lived Experience, Women’s, Men’s, Carers, Domestic Abuse, LGBTQ+ networks), stonewall top employer, veteran gold employer and reverse mentoring.

The trust did not ensure they had robust governance systems in place to allow full oversight at board level of the risk to patients. This failure put patients at risk of avoidable harm.

We found the trust board failed to ensure that staff were trained and competent in the legal requirements of the Mental Health Act 1983 relating to rapid tranquilisation and restraint. They were also not aware of the incidents whereby patients had been given rapid tranquilisation without the mandatory consent or legal authorisation, and they neglected to safeguard those patients or fulfil their duty of candour to inform them of the breach.

Mangers provided mandatory training in medicines compliance; however, rapid tranquilisation was administered to patients without the required legal framework. We found that seven staff across the five wards had not completed the mandatory medicines compliance training and 10 staff had not completed the annual medicines compliance training. Managers did not ensure that those staff who had undertaken the required training were following trust policy and putting patients at risk of avoidable harm.

We found that the trust did not consistently ensure timely discharge of patients no longer requiring inpatient care nor did they consistently implement internal systems to explore or address barriers to discharge planning. Although some barriers to timely discharge were outside the trust’s direct control, the trust failed to take a leadership role in ensuring that internal systems were robust enough to coordinate safe, collaborative discharge plans.

For example, senior leaders did not ensure that internal systems effectively secured, or explored barriers to, attendance from Community Mental Health Team (CMHT) professionals at multidisciplinary and discharge planning meetings. On ward 12, staff told us that there was a clear need for a discharge coordination role to improve discharge planning and reduce the need for staff to be diverted from their roles to coordinate discharge. Without identifying and addressing these obstacles, discharges could not always be planned collaboratively or safely with the external teams responsible for ongoing care, increasing the risk of delays and poorly coordinated support after leaving hospital.

Hospital-avoidance plans were not implemented consistently, resulting in patients being admitted, often out of hours and when agreed community care plans stated that hospital admission was not the preferred or most therapeutic option. This showed that the trust did not provide the leadership and coordination needed to make community-based alternatives work in practice, leading to unnecessary admissions and avoidable disruption to patients’ recovery.

We found that the trust board did not have sufficient oversight and control over multiple and sustained episodes whereby patients had received poor care. Although leaders were made aware of this, investigated them and produced recommendations, they failed to implement and embed them.

We found that senior leaders did not ensure that there was a culture of learning from incidents or audits. Senior leaders did not ensure that staff were provided with adequate supervision or reflective practice.

Without a culture of learning, staff lacked the guidance and confidence to improve their practice, leading to a risk of incidents repeating due to a failure to identify where practice should be improved. As a result, patients were at risk of ongoing harm and potential breaches of their human rights.