Lincolnshire Partnership NHS Foundation Trust

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

Leaders were open and transparent about the challenges facing the ward. New senior roles had strengthened visibility and accountability, and governance structures such as fortnightly improvement meetings and oversight groups were in place.

However, these systems had not yet delivered consistent improvement in safety or culture. Learning from incidents and safeguarding enquiries was not yet embedded, and incident grading often underestimated the level of harm. The quality improvement plan was active but many actions were still in progress, with completion dates into 2026.

We found this to be a breach of Regulation 17.

Leaders showed honesty, commitment and integrity but governance and learning systems were not yet mature enough to ensure that improvements were sustained or embedded.

This service scored 43 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Leadership visibility and accountability had improved on the Vales. A new clinical lead and service manager were in post and engaged with daily operations.

However, communication about priorities was inconsistent, and the pace of change felt difficult for staff. Development opportunities were increasing, but reflective-practice attendance remained low. Governance processes were still embedding and their impact on culture was limited.

Leaders on the Vales were visible and approachable and promoted openness. Staff, however, said they did not always feel supported or valued and some described favouritism or discrimination. Leadership capacity had increased, but systems to promote inclusion and restore confidence were not yet effective.

Freedom-to-speak-up processes were available on for staff working on the Vales. Staff said they could raise concerns but were not always confident that action would follow. Leaders had started listening events to rebuild trust, but the culture was still cautious.

Equality and inclusion processes were improving, supported by ‘every voice’ sessions and a ‘tackling racism action group’. However, discrimination continued to affect staff relationships on the Vales, and changes were too recent to show measurable impact.

Leaders had failed to ensure that effective governance systems were in place to assess, monitor and improve the quality and safety of the services provided and to mitigate risks to service users and staff on the Vales.

Serious incidents were not effectively reviewed or used to inform improvements. The reporting of the severity of incidents were inappropriately graded and therefore, did not allow for thematic learning and prevented the trust from applying the Patient Safety Incident Response Framework (PSIRF) effectively.

Findings from safeguarding enquires and processes were not integrated in the services governance. Therefore, learning from these events and mitigating the risk of further similar incidents was poor.

We do acknowledge that governance systems had started to improve but were not yet embedded. The quality improvement programme provided structure, but actions were ongoing and not yet embedded. Learning from incidents and safeguarding was inconsistent, and gaps in records remained.
 

Partnership working with the commissioning board and local police had strengthened oversight and staff safety on the Vales. Patient and carer engagement forums existed but attendance varied. Plans were in place to expand collaboration with families and external professionals.

Systems for learning and improvement were in place, and leaders on the Vales were committed to embedding a culture of safety. Incident reviews were completed and discussed in governance meetings, and reflective-practice spaces were available for staff.

However, these systems were not yet effective in driving improvement. We reviewed 58 incidents between 30 September 2025 and 15 October 2025 and found repeated patterns of harm that had not led to meaningful change. Incidents involving airway occlusion, ligatures and assaults continued to occur despite increased observation levels and updated risk plans.

Several incidents required urgent physical interventions such as back slaps or abdominal thrusts, yet were graded as “low harm.” This underestimation of severity of these incidents limited opportunities for learning and meant that risks were not always recognised or escalated appropriately.

There was limited evidence that learning was shared with staff or translated into safer practice. Reflective-practice sessions and post-incident debriefs were available but not well attended, meaning staff missed opportunities to reflect and learn collectively.

Overall, leaders were committed to improvement and innovation on the Vales, but learning systems were at an early stage and not yet capable of producing sustained, measurable change.