Lincolnshire Partnership NHS Foundation Trust

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment, and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

At our last assessment we rated effective as good. At this assessment, the rating has remained good. Staff assessed the physical and mental health of all patients on admission. They developed individual care plans which were reviewed regularly through multidisciplinary discussion and updated as needed. Staff provided a range of treatment and care for patients based on national guidance and best practice. The ward team included or had access to a range of ward-based specialists required to meet the needs of patients on the ward. Staff from different disciplines worked together as a team to benefit patients. Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Health Act Code of Practice and discharged these well.

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 maximise the effectiveness of people’s care and treatment by assessing and reviewing their health, care, wellbeing and communication needs with them.

We scored the service as 3. The evidence showed a good standard. The service made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

We reviewed 7 care records. All records demonstrated that staff completed comprehensive assessments with patients within required timescales, including those due within 72 hours of admission and others within seven days. These timescales were adjusted where necessary to reflect the patient’s physical and mental health on admission. Assessments were completed to a good standard and were reviewed regularly by the ward team.

Care plans were holistic, person‑centred, and designed to meet individual needs while supporting meaningful and achievable outcomes. Records were reviewed and updated regularly. Communication needs and preferences were clearly documented, and staff adjusted their approach using a range of methods to support understanding and involvement where required. Staff completed timely and thorough assessments covering physical, mental, emotional, and communication needs. These assessments were person‑centred and routinely reviewed with patients and, where possible, their families.

A combination of clinical tools and professional judgment were used to build a detailed understanding of each individual’s needs. Patients and, where appropriate, their families participated in their care and treatment planning, and told us they felt involved, listened to, and their needs and preferences were understood and met. One patient told us, “Staff always help me in my ward round, and we talk about the things I might need to help me get well.” Due to diagnosis and presentation, some patients were not always able to be fully involved. On these occasions, staff supported involvement as much as possible and adhered to the appropriate legal frameworks when a patient lacked the capacity to consent and make informed decisions. Where patients were unable to communicate their needs directly, staff supported their families to have input into assessments, care planning, and risk management.

Description: We plan and deliver people’s care and treatment with them, including what is important and matters to them and in line with legislation and current evidence-based good practice and standards.

We scored the service as 3. The evidence showed a good standard. The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards. Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Health Act Code of Practice and discharged these well.

Staff followed National Institute for Health and Care Excellence (NICE) guidance and accessed regular clinical updates to ensure that care remained aligned with current best‑practice standards. We observed care that reflected contemporary evidence‑based approaches. Staff supported patients with their individual dietary needs, providing tailored assistance where required. Hydration and nutritional needs were assessed and monitored in line with national guidelines, with consistent and accurate documentation recorded in patients’ care plans.

Occupational therapists assessed patients using the Model of Human Occupation Screening Tool (MOHOST). This is an evidence-based assessment to evaluate patients occupational functioning, including motivation, habits, skills and environment. It was evident with in the care records that interventions had been tailored to patients’ individual needs following this assessment. Staff were encouraged to adopt innovative and evidence‑based practices to improve patient outcomes and continually enhance the quality of care.

The Francis Willis Unit participated in several external quality assurance and oversight processes that supported continuous improvement and adhered to national standards. The service is an active member of the Royal College of Psychiatrists’ Quality Network for Forensic Mental Health Services (QNFMHS). The next scheduled peer review is due in April 2026, and the unit’s current membership remains valid until July 2026. Participation in this network provided independent evaluation, benchmarking against national standards, and opportunities for shared learning with other forensic services.

In addition, the service was subject to routine quality oversight visits from commissioners. They undertook regular reviews as part of the contractual and quality governance framework for secure services. The Francis Willis Unit submitted quarterly quality reports to commissioners, with a clear focus on the delivery of safe, effective, and evidence‑based care. These processes provided external assurance and to help inform local service development and improvement activity.

At the time of the assessment, 90% of 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 reported having straightforward 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.

Description: We work effectively across teams and services to support people, making sure they only need to tell their story once by sharing their assessment of needs when they move between different services.

We scored the service as 3. The evidence showed a good standard. The service worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

Patients and their families experienced coordinated care across teams and services. One patient told us, “All the people involved in my care work well with me, they listen to me and I feel heard.” The service promoted a multidisciplinary approach, including doctors, nurses, psychologists, occupational therapists (OTs), occupational therapy assistants (OTAs), speech and language therapy (SALT), a dietician, and health care assistants (HCAs). External partners, for example, assertive transitions service (ATS) team, and community-based forensic mental health teams (CFMHT) were invited to care and treatment reviews, which ensured continuity and effective joined up care for patients, and their families.

Description: We support people to manage their health and wellbeing so they can maximise their independence, choice and control, live healthier lives and where possible, reduce their future needs for care and support.

We scored the service as 3. The evidence showed a good standard. The service supported people to manage their health and wellbeing to maximise their independence, choice and control. The service supported people to live healthier lives and where possible, reduce their future needs for care and support.

Staff supported people to manage their health and wellbeing. Staff recorded in patient case notes when they have been offered education on smoking cessation or food preparation. Staff held session for patients to increase their physical activity such a walking group.

Regular health assessments were completed, and staff made timely referrals to specialist services such as occupational therapy to address individual needs. The service prioritised early identification of potential health risks, enabling prompt intervention to maintain wellbeing and prevent avoidable deterioration.

Staff empowered patients to take an active role in managing their own health, promoting healthier lifestyle choices and encouraging them to retain as much independence as possible.

A wide range of health‑promoting activities was offered, including the Jazz Café, “Every Voice” meetings, “Think, Speak, Share” groups, tai chi, yoga, walking groups, football, table tennis, and gym sessions. These activities supported both physical health and emotional wellbeing.

Meals were freshly prepared on site, with healthy options readily available. Staff encouraged and supported patients to make positive nutritional choices. One patient told us, “The staff help me to have a good sleeping routine, they also advise you on healthy food options.”

Description: We routinely monitor people’s care and treatment to continuously improve it and to ensure that outcomes are positive and consistent, and that they meet both clinical expectations and the expectations of people themselves.

We scored the service as 3. The evidence showed a good standard. The service routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves.

The service had robust systems in place to ensure consistent and positive outcomes. Staff actively contributed to monitoring and improving care, using technology to support these processes. Care plans were reviewed regularly to keep them up to date and aligned with people’s changing needs.

The service engaged in a range of benchmarking and collaborative initiatives that supported continuous quality improvement and alignment with national best practice. Outcome measures used within the unit were recognised as examples of good practice and received funding support from an east midlands innovation sector of the NHS. This enabled the service to participate in regional quality initiatives and strengthened the use of evidence‑based tools in evaluating patient progress and service effectiveness.

In addition, the unit contributed to national clinical benchmarking through the prescribing observatory for mental health (POMH‑UK). Recent POMH‑UK data relating to clozapine prescribing included only two patients from the Francis Willis Unit out of a total cohort of 180 patients across the trust. These collaborative activities demonstrate the service’s commitment to external scrutiny, shared learning and continuous improvement against recognised national standards.

Description: We tell people about their rights around consent and respect these when we deliver person-centred care and treatment.

We scored the service as 3. The evidence showed a good standard. The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

Patients were supported and enabled to make their own decisions about their care, treatment, and support wherever possible. When individuals lacked mental capacity, staff completed decision‑specific capacity assessments and recorded the outcomes clearly including advocacy referrals were submitted for each patient when admitted onto the ward.

The service ensured patients were supported and empowered to make their own decisions about their care, treatment and support were possible. One patient told us, “When staff want to share information about me, they tell me who with, why they need to share it and ask for my consent.” For patients who may lack mental capacity, staff assessed and recorded their capacity on a decision-specific basis, emphasising significant decisions to safeguard the patient, and protect their interests. Staf adhered to the Mental Capacity Act 2005 (MCA) guidance and supported individuals to make decisions for themselves wherever possible. If patients lacked capacity to make informed decisions, staff followed the appropriate process and involved family members and the relevant professionals in any of the decisions made on their behalf. Staff considered patient’s wishes, feelings, cultural and religious beliefs, social background, and history when making decisions.

For patients detained under the Mental Health Act 1983, staff complied with all statutory requirements and ensured that patients’ rights were upheld. Patients were informed of their rights both verbally and in writing, including their right to appeal. Section 132 rights were explained on admission and repeated regularly or whenever there were changes to Mental Health Act status, Responsible Clinician (RC), or treatment plans.

Medical staff discussed with patients their treatment plans including medication. These discussions were fully recorded in the patient records. If the patients had capacity to consent to treatment doctors completed a T2 consent to treatment form which was then uploaded into the patient records. If the patient did not have capacity to consent or refused to consent then medical staff requested a Second Opinion Appointed Doctor (SOAD) to review the treatment plan, which included medication. The request and the outcome of the SOAD was clearly written in the patient care records. A T3 form was fully completed and uploaded into the patient care records.

Staff sought patients consent to enable them to search their person and property if there were concerns about safety. This consent was clearly recorded within the patient record.

One staff member told us, “You should always consider the patient’s capacity to understand and retain information, always considering individual vulnerabilities and potential safety issues.”