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 remained good. This meant people were safe and protected from avoidable harm.

The unit was safe, clean, well equipped, well furnished, well maintained and fit for purpose. The staff team did recognise that the environment was outdated and required updating with concerns escalated to the estates team. Staff assessed and managed risks to patients and themselves well. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. The provider used systems and processes to safely prescribe, administer, record and store medicines. Staff managed patient safety incidents 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 have a proactive and positive culture of safety based on openness and honesty, in which concerns about safety are listened to, safety events are investigated and reported thoroughly, and lessons are learned to continually identify and embed good practices.

We scored the service as 3. The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Staff and leaders proactively identified learning from incidents, disseminated this information across teams, and used it to drive measurable improvements in care. During episodes of agitation or aggression, staff responded promptly, completed appropriate incident reporting, and ensured care plans and risk management plans were updated in a timely and accurate manner. Post-incident debriefs were conducted with both patients and staff, supported by the psychology team, who also facilitated individual and group reflective sessions and provided additional support when required.

We reviewed the units last 28 days of patient incidents from the time of our visit. A total of 49 patient safety incidents were reported during this period, and all were appropriately documented and actioned. The majority of the incidents involved the same patient, inflicting low level self-harm. All incidents were either “low” (minimum harm caused) or “no harm caused”.

Staff demonstrated a strong understanding of the duty of candour, maintaining open and honest communication with patients and families when incidents occurred, including offering explanations and apologies where appropriate. Freedom to Speak Up (FTSU) champions were available to provide further support to staff as needed.

Learning from incidents was embedded within routine practice through structured morning meetings, handovers, team discussions, and monthly operational reviews. Teams consistently used both positive and negative feedback to inform improvements in practice and service delivery.

Managers and clinical leads provided regular feedback to staff following investigations, ensuring lessons learned were clearly communicated and translated into practice improvements.

One staff member shared “Communication after incidents is very good. We are given debriefs and offered sessions with the psychology team. We are kept up to date of any updates during investigations and the learning from incidents is shared with all staff and patients if appropriate.”

Description: We work with people and our partners to establish and maintain safe systems of care, in which safety is managed, monitored and assured. We ensure continuity of care, including when people move between different services.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Staff and leaders at the Francis Willis unit worked closely with their commissioners. Through joint working the staff team had robust systems to ensure safe admissions, care transfers, and discharge planning. Referral documentation, including clinical history, risk assessments, and care plans, was reviewed thoroughly.

Upon receiving a referral, the service organised a face‑to‑face assessment, which always included a mental health nurse as part of the assessment team. Staff reported that this approach helped confirm the patient’s suitability for the service and ensured their needs could be met safely. Prior to admission, the team received relevant information about the patient, supporting a smooth transition and enabling staff to deliver consistent, coordinated care.

A structured admission pathway was followed, with patients encouraged to participate as much as possible. Actions were completed, reviewed routinely, and supplemented with follow‑up information to support timely care planning and robust risk assessment.

Leaders promoted early planning and clear communication between teams. Discharge processes involved coordination with external services to ensure safe transitions and maintain continuity of care. Staff worked to minimise unnecessary delays and remained focused on facilitating timely, well‑supported discharges.

Patients felt well-supported and reassured during referral, admission, transfer, and discharge processes, which helped reduce anxiety during times of transition. One patient told us, “The staff are really good at welcoming new patients to the ward; they make you feel safe and comfortable.” They had information about what to expect from their care and treatment available to them in a variety of formats to suit individual needs.

Description: We work with people to understand what being safe means to them as well as with our partners on the best way to achieve this. We concentrate on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect, and we make sure we share concerns quickly and appropriately.

We scored the service as 3, reflecting a good standard of performance. Evidence demonstrated that the service worked effectively with individuals and healthcare partners to understand what safety meant to them and how best to achieve it. The service focused on improving people’s wellbeing while upholding their right to live safely and free from bullying, harassment, abuse, discrimination, avoidable harm, and neglect. Concerns were escalated promptly and through appropriate channels.

Staff demonstrated a strong and consistent understanding of safeguarding, confidently identifying risks and taking timely action to protect patients from harm. They responded appropriately to concerns relating to abuse, neglect, or discrimination and worked collaboratively with external agencies, including the local authority safeguarding team, when required.

Safeguarding was embedded within routine practice and discussed regularly through daily morning meetings, dedicated safeguarding meetings, multidisciplinary team (MDT) discussions, and safety huddles. Staff were supported by safeguarding leads who provided guidance and oversight.

Staff showed clear knowledge of the Deprivation of Liberty Safeguards (DoLS) and ensured patients understood their rights under the Mental Health Act 1983, the Mental Capacity Act 2005, and the Equality Act 2010.

The service had effective safeguarding systems, policies, and procedures in place that upheld patients' human rights and promoted a culture of safety. Safeguarding investigations were defined as concerns relating to potential harm by staff or the organisation.

A review of internal records and electronic incident reports from November 2025 to January 2026 identified no safeguarding concerns. The trust’s safeguarding team conducted an independent review of incident forms for any allegations involving staff, students, contractors, or volunteers, and found none. A separate review of incidents involving patient‑on‑patient harm found no cases requiring safeguarding referral.

As part of the wider review, incident forms incidents listed under ‘violence, abuse and harassment’, ‘sexual safety’, and ‘self‑neglect’ were examined. Nine incidents were recorded under ‘violence, abuse and harassment’, mostly involving verbal disputes between patients that were appropriately managed. One incident involved hostility towards staff and appeared to have been incorrectly categorised.

Patients consistently reported that they felt safe on the ward and were confident to raise any concerns. They felt that staff would respond appropriately if they felt unsafe or had worries about the wellbeing of others.

Leaders ensured that staff had the knowledge, support, and confidence needed to take prompt and appropriate action to safeguard the patients in their care. Staff demonstrated a clear understanding of their responsibilities. Staff took account of equality and human rights legislation when applying any form of restriction. Where rapid tranquilisation was necessary, it was used appropriately, proportionately, and documented in line with national best practice standards.

Description: We work with people to understand and manage risks by thinking holistically so that care meets their needs in a way that is safe and supportive and enables them to do the things that matter to them.

We scored the service as 3. The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. Staff worked with patients to understand and manage their individual risk profiles. Staff completed detailed risk assessments for all patients. They clearly documented the patients historical and current risk. This included predisposing factors to risk, precipitating factors and preventative factors which enabled staff to support patients when their risk increased.

Staff worked with patients to understand and manage their individual risk profiles. Staff completed detailed risk assessments for all patients. They clearly documented the patients historical and current risk. This included predisposing factors to risk, precipitating factors and preventative factors which enabled staff to support patients when their risk increased.

Staff assessed the risks associated with patients accessing the internet. Where risks were identified, interventions were implemented to help patients use the internet safely while receiving care and treatment.

Patients told us that staff understood their individual risks and intervened and responded quickly to support patients to minimise any distress and to decrease risk. One patient told us, “The staff know all our risks and support you to feel safe as an individual.”

We reviewed 7 patient risk assessments and found evidence of fully completed assessments with all current and historical risks including index offences. Records and plans were updated after incidents and included formulations and future mitigations. All risk assessments clearly identified predisposing factors, precipitating factors and preventative factors. Safeguarding was documented within risk all assessments. These included professional input from the unit’s social worker with safeguarding discussions and interventions in place family involvement.

Care plans and risk assessments were person-centred with obvious patient and family involvement and were reviewed in line with organisational policy. One patient told us. One patient told us “I am involved in my care. I’ve got a fantastic nurse, and the other support staff who are there for me and help me to be involved.”

Staff took a proportionate and balanced approach to risk, welfare checks and observations were completed in line with the patients’ care plan and based on individual patient need. The patient records we reviewed showed observations were completed as prescribed.

The staff were proud to share that restraint and seclusion were rarely used with records reflecting this. The ward staff participated in the provider’s reducing restrictive interventions (RRI) policy. We reviewed the unit’s patient restraints and seclusion records from the months of November, December 2025 and January 2026. There were 6 incidences of low-level restraint applied within the service. All 6 incidences were documented and were in line with the providers policies and procedures. Reviewing information across the same period, we found that there was 1 incident of seclusion in the month of January 2026.

Staff ensured that patients’ physical and emotional needs were met in a positive and person‑centred manner, while consistently upholding their rights and dignity. They adopted a calm and supportive approach during episodes of distress, helping to maintain safety and reduce the risk of escalation.

Patients and their families were actively involved in developing and reviewing risk assessments. Care records demonstrated clear evidence of full participation in multidisciplinary team (MDT) discussions. Where families were unable to attend in person, staff supported their involvement via online technology.

Staff worked collaboratively across disciplines, including with the psychology team, to help patients understand their individual risks and develop positive strategies to manage them. A variety of communication methods were used to ensure information was accessible and tailored to individual needs, including easy‑read materials and emoji‑based visual documentation for people with language barriers or more complex communication requirements.

At the point of admission, referrals were completed by primary nurses on behalf of the patient for advocacy support. The allocated advocate would then meet with patient as and when required including attending individual patients ward round meetings, care programme approach (CPAs) and tribunals. Advocacy posters and easy read documents for patients were visible within the wards. Staff members told us that that patients were regularly reminded of the advocate services that were available to them especially during 1:1 sessions and ward rounds.

Description: We detect and control potential risks in the care environment and make sure that the equipment, facilities and technology support the delivery of safe care.

We scored the service as 3. The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Ward teams carried out regular environmental risk assessments throughout the day and night. Consistent auditing ensured potential hazards were identified promptly, with actions taken to mitigate risks. Ligature risks were assessed, and appropriate measures were in place to manage and reduce any potential harm. CCTV were installed across the service to safeguard patients and staff and reduce blind spots.

A designated security nurse completed safety audits during every shift and shared findings during handover meetings. This role ensured continuous monitoring of the environment and timely identification of any risks.

Patients and staff felt safe within the environment. The service maintained clean, well-equipped spaces that supported both physical and mental wellbeing and enabled the safe delivery of care. Equipment was properly maintained, stored securely, and used appropriately for its intended purpose. It was observed and shared by the staff team that the environment as whole does need upgrading and improving. There were no risks towards patients or staff found at the time of our visit, all concerns were logged and escalated appropriately to the estates team. The ward was compliant with national cleaning standards, and the service manager regularly reviewed all actions from audits to ensure timely follow up.

Staff carried personal alarms and used radio communication systems for safety. Patients had access to nurse call systems in bedrooms, bathrooms, and throughout the environment, ensuring they could request assistance whenever needed. One patient told us “The staff are always around, and they have alarms for if anyone needs help. There are alarms on the walls everywhere for patients to use if we need to.”

Clinic rooms were fully equipped with resuscitation equipment and emergency medicines, which staff checked and audited regularly to maintain readiness for any emergency.

Outdoor spaces were available including a purpose-built space where patients could use vape pens. The spaces were well-maintained and secure; however, it was agreed that upgrades were necessary.

Equipment and technology were kept in good condition, enabling staff to deliver safe and effective care. The service had robust processes to monitor the safety and maintenance of the environment and premises. Staff understood what was required to provide and maintain environments that protect people from physical harm.

Description: We make sure there are enough qualified, skilled and experienced people, who receive effective support, supervision and development and work together effectively to provide safe care that meets people’s individual needs.

We scored the service as 3. The evidence showed a good standard. The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Leaders routinely monitored and reviewed staffing levels to ensure they were aligned with the needs of the service and the patients. The established safe‑staffing requirement for the unit was two registered nurses and three health care assistants for the day shift, with staff generally working long‑day shifts in line with their employment contracts. For the night shift, the required establishment was two registered nurses and two health care assistants.

Where necessary staffing levels were flexed to maintain a safe skill mix. For example, in the event of registered nurse absence, the staffing model could be temporarily adjusted to one registered nurse and three health care assistants, ensuring appropriate coverage and continuity of care.

All safe‑staffing establishment requirements were met throughout our four‑week review period. In some cases, safe staffing numbers were achieved by using the internal bank staff, with no agency staff were required during this timeframe. This ensured consistency of care and maintained familiarity between staff and patients.

The service demonstrated strong forward‑planning arrangements for workforce management. Rotas were published three months in advance, allowing staff adequate notice and supporting effective work–life balance. In addition, monthly rota hygiene meetings, facilitated by the health roster team, were held to review staffing patterns, monitor compliance with safe‑rostering standards, and ensure that any emerging gaps or pressures are identified and addressed in a timely manner.

The trust followed a temporary staffing Protocol to support clinical areas in safely managing staffing shortfalls. This protocol included the use of overtime, internal bank staff, and only in exceptional circumstances agency staff to cover registered nurse vacancies. Staffing pressures across all inpatient units were reviewed each weekday morning, ensuring real‑time oversight and coordination. Where necessary, staff may be redeployed from other teams, and support may be provided by ward managers, service managers, or other appropriate professionals to maintain safe staffing levels.

Across the three‑month period reviewed, all nursing‑related duties were delivered without disruption, despite episodes of registered nurse or senior healthcare support worker absence. Patient care and treatment continued safely, and there were no incidents reported that related to staffing deficits caused by sickness absence.

Housekeeping duties were fully covered throughout the period, and security administration support was also in place as required. However, cover for occupational therapy assistants, physiotherapy assistants, and social workers were not available during this timeframe. Despite this, there was no evidence that the absence of these roles negatively impacted patient safety or the continuity of essential nursing care.

A review of staff sickness and absence data for November 2025, December 2025, and January 2026 showed overall sickness and absence levels remained below the trust’s target threshold, indicating stable workforce attendance and effective absence management processes.

Patients were well supported by well-trained visible, and available staff. One patient told us, “The staff are well trained and better than other places I’ve been.” Another patient told us, “The staff are really good, if you need them, they’re there for you.”

Recruitment processes were robust and ensured that all staff, including bank staff, had up‑to‑date disclosure and barring service (DBS) checks and the necessary qualifications, experience, and competencies for their roles. Disciplinary and capability procedures were applied proportionately, routinely reviewed, and demonstrated no evidence of bias relating to any protected characteristics.

Staff reported feeling supported by the leadership team and stated that they received regular clinical and managerial supervision each month. All members of the team also completed annual appraisals and personal development reviews. Data reviewed for the end of January 2026 showed strong compliance, with clinical supervision at 96.30%, managerial supervision at 94.44%, and staff appraisals at 100%. Records confirmed that supervision and appraisal activity consistently met, and often exceeded, the organisation’s required standards.

Mandatory and role‑specific training was also completed and maintained by staff, with an overall compliance rate of 96% at the time of assessment. The training available was appropriate to the needs of the patient group, and staff demonstrated confidence and competence in delivering safe, effective and person‑centred care.

Opportunities for learning and professional development were available to staff at all levels within the service. Where instances of underperformance were identified, these were addressed promptly and appropriately through established management processes.

Description: We assess and manage the risk of infection, detect and control the risk of it spreading and share any concerns with appropriate agencies promptly.

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The provider had clear and robust processes for assessing and managing infection risks, fully aligned with current national guidance. Regular cleaning schedules and infection prevention and control (IPC) audits were undertaken, and any concerns identified were addressed promptly. Information relating to infection risks was communicated effectively to staff, patients, visitors, and external partners. Roles and responsibilities for IPC were clearly defined, and staff received ongoing training in accordance with organisational policy and best practice standards.

All staff were responsible for ensuring that daily and weekly cleaning checks were completed accurately and consistently documented. Staff were required to report any IPC issues identified during the day, ensuring that these were recorded, escalated to the ward manager, and reviewed during the morning MDT meeting, where actions were agreed and implemented without delay. All ward areas were clean, well maintained, and visibly hygienic. Cleaning records were up to date and demonstrated consistent auditing processes. Staff showed strong awareness of their responsibilities in maintaining high standards of cleanliness. Patients reported feeling confident in the IPC measures in place and expressed reassurance that staff were taking appropriate precautions to protect them from infection and harm.

Patients were confident in the infection prevention and control (IPC) processes in place and felt assured that staff were taking necessary precautions to protect them from the risk of infection and potential harm. One patient told us “The cleaners are always around, and they always clean your bedrooms. Staff also clean up and keep things nice at night.”

Staff adhered to IPC procedures, followed handwashing guidance, used personal protective equipment (PPE) appropriately, and cleaned equipment in line with best practice standards.

Description: We make sure that medicines and treatments are safe and meet people’s needs, capacities and preferences by enabling them to be involved in planning, including when changes happen.

We scored the service as 3. The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

We reviewed medication audits for November and December 2025 and found no reported or identified medication errors on the Francis Willis Unit during this period. The trust reported that two medication errors occurred in January 2026. Both incidents were fully investigated in line with organisational procedure, and no harm was caused to the patients involved. All affected patients were informed of the incidents and kept updated as required.

Staff made sure that medicines and treatments were safe, in line with national and legislative guidance and met patient’s needs. Staff ensured that patients consented to their prescribed medication (T2) or had documented authorisation who patients who were incapable of consent or refused to consent for treatment in place (T3).

We found the use of social stories within the service to support patients understand their care such as their depot medication. Individual patient treatment plans were very clear. When required if a patient refused medication treatment or were deemed incapable of consenting to medication staff requested a second opinion appointed doctor (SOAD) to review individual treatment plans. This was in line with national guidance.

The newly acquired electronic medication chart system was in place and staff found the system easy to use. The system flagged patients who were on high dose antipsychotic medication which prompted staff to ensure that the additional physical health checks were completed. It would also flag in doctors prescribed medication that that patient had not consented to, safeguarding patients from the improper use of medications.

Storage of medication were in line with national guidance. The clinic room fridge was clean, not overstocked and kept at the correct temperature ensuring the efficacy if the medication stored in it.

Controlled drugs were in order, stored correctly and checked daily. Control drugs (CD’s) were stored correctly within a locked cabinet that was bolted to the wall as per national guidance. CD drugs keys were kept on separate key bunch to normal medication keys (as per national guidance). One CD medication that was in stock that we reviewed tallied with the CD register. All checks were completed by two staff members with two dated signatures observed.

The clinic room was equipped with medical equipment to monitor patients’ physical health, all of which, were calibrated, clean. Emergency grab bags and oxygen were in place, which staff checked regularly.

Staff supported patients to be involved in decisions about their medicines. One patient told us, “Any changes in my medicine is discussed in ward round, and 1 2 1 time with my nurse.” For those who had capacity, staff ensured they understood what their medicines were for and involved them in any discussions regarding changes to their treatment. Where patients lacked capacity, and were not able to fully understand or participate, due to diagnosis related impairment, staff adhered to processes in line with the Mental Capacity Act 2005 and the Mental Health Act 1983. Care plans we reviewed reflected each person's level of understanding and evidenced the level of involvement they had in making decisions about their medicines and treatment.

The staff nurses administered medicines in line with ‘Stopping Over-medication of People ‘with a learning disability, autism, or both (STOMP). We reviewed all prescribing, and administration records and found no concerns.

Staff reported uncertainty about how the new electronic prescribing system would interface with Section 62 arrangements. Specifically, they were unclear whether a Section 62 form would need to be uploaded to the system before medication could be prescribed. Without a completed Section 62, T2, or T3 form, it was not evident how prescriptions would be authorised.

Clarification was obtained from the ward’s clinical lead following discussions with the pharmacy team and the electronic prescribing system lead. They confirmed that the paper Section 62 form remains the legal document and must always be completed in full.

However, a Section 62 can also be recorded within the electronic medication system in the same way that T2 and T3 certificates are currently managed. In practice, this means the prescriber may override the alert initially by indicating that a Section 62 is in place. The supporting documentation can then be uploaded or added to the system afterwards, recognising that in many situations treatment is required urgently.