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

Well led- This means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question Good. At this assessment the rating has remained Good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

Leaders had the skills, knowledge and experience to perform their roles. Staff knew and understood the provider’s vision and values and how they applied to the work of their team. Staff felt respected, supported and valued. Governance processes operated effectively. Performance and risk were managed well. Teams had access to the information they needed to provide safe and effective care. Staff collected analysed data about outcomes and performance. They used this to identify improvements.

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 shared vision, strategy and culture that is based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding and meeting the needs of people and our communities.

We scored the service as 3. The evidence showed a good standard. The service had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The staff and leaders demonstrated a clear and shared vision underpinned by a culture of openness, honesty, equality, diversity, and inclusion. Staff at all levels consistently reflected the organisation’s values in their day‑to‑day practice. Leaders communicated the service’s priorities effectively, ensuring the vision was well understood across the workforce and embedded within operational and clinical practice. Staff we spoke with were able to articulate the service’s aims and described how their roles contributed to achieving them.

Leaders took proactive steps to identify and address workforce inequalities, creating an inclusive environment where staff felt respected, supported, and treated fairly. They showed a strong understanding of equality, diversity, and human rights and modelled behaviours aligned with these principles in their interactions with patients, staff, and external partners. This contributed to the provision of equitable, person‑centred care across the service.

Staff were given meaningful opportunities to contribute to discussions about the service’s direction and future plans, particularly during periods of change, development, or transformation. Leaders sought staff views through meetings, forums, and informal conversations, and staff told us they felt their contributions were valued and taken seriously. This inclusive approach helped staff feel involved in shaping the service and reinforced a sense of ownership and shared purpose.

Staff demonstrated a good understanding of how their individual responsibilities supported the delivery of safe, high‑quality care. They described feeling supported by leaders and confident that their work made a positive difference to patient outcomes. This alignment between strategic vision and frontline practice helped sustain a cohesive, values‑driven culture throughout the service.

The trust recently reviewed and refreshed its organisational strategy and core values, working collaboratively with people who used services, their families and carers, and staff across all teams. This inclusive approach ensured that the updated strategy and values accurately reflected the priorities, experiences and expectations of the trust community.

Following the finalisation of the new strategy and values, all teams within the organisation were asked to reflect on how these values were demonstrated in their day‑to‑day practice and how they aligned with the revised strategic direction. The Francis Willis Unit undertook this work during their team away day in October 2025. As part of this session, staff explored how the trust’s values were embedded within the culture of the ward and how they guided behaviours, decision‑making and the therapeutic environment.

This work directly informed the development of the ward’s updated model of care, ensuring that it was fully aligned with the trust’s strategic aims and reflected a values‑led approach to providing high‑quality, person‑centred care.

Description: We have inclusive leaders at all levels who understand the context in which we deliver care, treatment and support and embody the culture and values of their workforce and organisation. They have the skills, knowledge, experience and credibility to lead effectively and do so with integrity, openness and honesty.

We scored the service as 3. The evidence showed a good standard. The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Leaders demonstrated a thorough and detailed understanding of the services they managed and consistently supported their teams to deliver safe, high‑quality, person‑centred care. They were visible and approachable within the service, making themselves accessible to patients, families, and staff. Leaders modelled inclusive, respectful behaviours that aligned with the organisation’s values and contributed to a positive and supportive culture.

Leaders possessed the necessary skills, experience, and professional expertise to carry out their roles effectively. Defined leadership structures ensured clear accountability, with staff at all levels understanding their responsibilities and the wider priorities of the service. Leaders remained aware of emerging issues, operational pressures, and risks, and demonstrated a proactive approach to addressing concerns before they affected care quality.

Leaders also took steps to identify and address any cultural or workforce issues that could impact staff wellbeing or the overall quality of care. They monitored staff morale, encouraged open discussion, and implemented supportive measures where needed.

This approach reinforced a culture of continuous improvement, professional development, and shared responsibility for delivering safe and compassionate care.

Description: We have inclusive leaders at all levels who understand the context in which we deliver care, treatment and support and embody the culture and values of their workforce and organisation. They have the skills, knowledge, experience and credibility to lead effectively and do so with integrity, openness and honesty.

We scored the service as 3. The evidence showed a good standard. The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Leaders promoted an open and transparent culture where staff felt safe to raise concerns. Concerns were listened to, acknowledged, investigated, and addressed in a timely and appropriate manner. Individuals who raised issues received regular updates, and outcomes were communicated clearly to support learning and improvement. Staff told us they felt confident to speak up and understood the whistleblowing procedures in place.

A comprehensive freedom to speak up (FTSU) policy and procedure was in operation. Staff had access to the FTSU Guardian, and freedom to speak up champions were based on the wards to provide local, accessible support. Staff reported that they knew how to raise concerns, felt encouraged to do so, and trusted that leaders would respond constructively.

FTSU concerns were routinely reviewed through established governance processes. Trends and themes were monitored and audited to identify any recurring issues. Where themes were identified, leaders developed and implemented action plans to address them and prevent reoccurrence. Staff expressed confidence that their concerns were taken seriously, acted upon, and led to meaningful positive change within the service.

This proactive, transparent approach contributed to a culture of psychological safety, continuous learning, and shared responsibility for maintaining high standards of care.

The staff team shared that there was no freedom to speak up concerns raised within the last 3 months of our visit period by the Francis Willis Unit staff. Alongside this The freedom to speak up (F2SU) guardian submitted a quarterly report to the people committee. This provided an organisation‑wide assurance and oversight of freedom to speak up activity across the trust. From this report actions and plans could be formulated to help support improvement.

Description: We value diversity in our workforce. We work towards an inclusive and fair culture by improving equality and equity for people who work for us.

We scored the service as 3. The evidence showed a good standard. The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

The service demonstrated a strong and sustained commitment to equality, diversity, and inclusion (EDI). The organisation’s values were embedded across all aspects of service delivery and staff experience. Leaders maintained clear oversight of the culture within the service and worked to ensure that staff were treated fairly and with kindness and respect. Instances of unfair treatment or inconsistent staff experience were promptly identified and addressed, particularly for staff with protected characteristics or those from marginalised or minority groups. Reasonable adjustments and flexible working arrangements were routinely offered to support individual staff needs and promote an inclusive working environment.

The service also demonstrated effective support for overseas staff through a well‑established sponsorship programme. The organisation’s international resourcing team provided structured guidance to help staff transitioning from overseas navigate the relocation process and adapt to working within the UK health system. The Relocation Service supported individuals with travel arrangements and securing appropriate accommodation to ensure a manageable commute to work. Service leaders ensured that all overseas recruits completed role‑specific induction, training, and competency assessments before undertaking their duties, helping to maintain safe and effective care.

Overseas staff told us they felt listened to, respected, and valued within the team. They described positive relationships with colleagues and reported feeling recognised for their contributions to the service. This reflected a supportive and inclusive culture where diversity was actively celebrated, and all staff were encouraged to thrive.

One staff member told us, “At first it was difficult moving to a new area, but the existing staff team made us feel safe and welcome."

Employment processes were robust and ensured that all applicants were treated fairly, consistently, and without discrimination, in line with the Equality Act 2010 and the trust’s equality, diversity and inclusion (EDI) Policy. Recruitment practices promoted equal opportunity and supported the appointment of staff from a wide range of backgrounds. The organisation actively encouraged applications from lesbian, gay, bisexual, transgender and queer or questioning (LGBTQ+) individuals and maintained an internal LGBTQ+ staff network, providing a dedicated space for peer support, visibility, and representation. Core human resource policies clearly reinforced a zero‑tolerance approach to discrimination on the grounds of sexual orientation or gender identity, helping to build a workforce that was inclusive and reflective of the diverse population using the service.

Leaders fostered an open, inclusive culture and maintained a strong stance against bullying, harassment, and victimisation. They took proactive steps to ensure that all staff—including those whose voices are less frequently heard—had meaningful opportunities to contribute to shaping the service. Staff reported feeling confident that they could raise issues without fear and that leaders were responsive and supportive.

Equality, diversity and inclusion were firmly embedded within the organisation’s values, policies, and strategic priorities. Leaders promoted EDI through visible role modelling, regular communication, and structured governance processes that ensured oversight of workforce culture, staff experience, and equitable opportunities. This commitment helped create a positive working environment where staff felt respected, listened to, and able to thrive.

Description: We have clear responsibilities, roles, systems of accountability and good governance to manage and deliver good quality, sustainable care, treatment and support. We act on the best information about risk, performance and outcomes, and we share this securely with others when appropriate.

We scored the service as 3. The evidence showed a good standard. The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

The service had well‑established and effective governance and management processes that supported the delivery of safe, high‑quality, and sustainable care. Clear structures ensured that staff understood their roles, responsibilities, and lines of accountability. Leaders held staff appropriately to account and ensured that expectations around professional standards, performance, and care quality were consistently reinforced.

Collaboration and communication were evident across the staff team and with external partners. This supported effective care coordination and ensured that patient needs were met promptly and appropriately. The service maintained a comprehensive and up‑to‑date risk register that was accessible to relevant staff. Risks were reviewed regularly and updated following incidents, audits, or changes in patient presentation. Staff understood how to escalate concerns and did so promptly, enabling leaders to respond quickly and take appropriate action.

Regular morning meetings, handovers, and multidisciplinary team meetings provided structured forums to discuss key operational and clinical topics. These included incidents, risks, safeguarding, complaints, patient admissions and discharges, and wider issues affecting care quality. Staff demonstrated good insight into learning from complaints, incidents, and audits, and they acted on recommendations. This supported a culture of continuous improvement, shared learning, and reflective practice across the service.

Leaders had access to timely, accurate, and relevant performance data, which supported effective oversight and informed decision‑making. Governance reporting systems ensured leaders could monitor trends, identify emerging risks, and evaluate the impact of improvement actions. The service submitted statutory and regulatory notifications to external bodies, including the Care Quality Commission, in line with legal requirements and within expected timeframes. This reflected a transparent and well‑led approach to regulatory compliance.

Description: We understand our duty to collaborate and work in partnership, so our services work seamlessly for people. We share information and learning with partners and collaborate for improvement.

We scored the service as 3. The evidence showed a good standard. The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

The service benefited from a wide range of established partnerships that supported patient care, advocacy, recovery, and safe discharge planning. Information about the independent advocacy provider, was clearly displayed in patient areas, ensuring that people knew how to access support. An automatic referral to the advocacy service was made for every patient on admission, promoting early engagement and safeguarding patients’ rights.

The unit also worked closely with an external service to support individuals with drug and alcohol needs. This partnership ensured that patients had access to specialist substance‑use support throughout their admission and into the community.

All patients were allocated a caseworker from their commission body as part of secure care pathway arrangements. This ensured consistent oversight of individual care pathways, supported progression planning, and strengthened communication between inpatient and community services.

The service maintained strong links with the integrated care board’s mental health, learning disabilities, autism and CAMHS commissioning team, enabling effective commissioning oversight, collaborative planning and joint problem‑solving around resource needs and complex discharges.

Patients may also be supported by the Section 75 social work team, with allocations made based on assessed needs. These social workers played an important role in discharge planning, community care arrangements, and ensuring that legal and social needs are fully addressed.

In addition, the Francis Willis Unit works collaboratively with trusts every voice programme, which partners staff with patient partners to ensure that patient experience and feedback actively influenced service improvements. This approach ensured that the patient voice was represented at all levels of the organisation and contributed directly to service development and cultural change.

Together, these partnerships demonstrated a strong, integrated approach to meeting the needs of patients and supporting positive outcomes across the care pathway.

Description: We focus on continuous learning, innovation and improvement across our organisation and the local system. We encourage creative ways of delivering equality of experience, outcome and quality of life for people. We actively contribute to safe, effective practice and research.

We scored the service as 3. The evidence showed a good standard. The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contribute to safe, effective practice and research.

The unit has begun piloting a new medicines key management system, aimed at improving security and ensuring safer and more efficient access to medication storage. Early feedback from staff has been positive, with the system expected to support more robust medicines management processes.

The former multi‑use room has been fully refurbished and repurposed into a dedicated social hub space. This development has been undertaken in collaboration with patients, who contributed to decisions about the layout, use and design of the room. The space is intended to promote social interaction, therapeutic engagement and a more positive ward environment.

To further enhance the patient experience, new furniture and a computer with controlled internet access have been purchased. Patients will be able to use this computer for appropriate, approved online activities, supporting communication, education and social connection. The room will also provide a welcoming and comfortable space for families visiting the unit.

The team has also engaged in a national quality improvement project with commissioners, focused on strengthening cultural awareness and enhancing person‑centred care. As part of this work, the service has reviewed its approach to ward rounds and explored how staff can develop greater cultural curiosity and sensitivity. One of the key outcomes of this initiative has been the introduction of a cultural café, developed in partnership with patients, to encourage dialogue, shared learning and cultural expression within the ward community.

In addition, a new ward round template has been designed to improve structure, transparency and patient involvement. The service is currently working with the trust’s IT department to integrate this template into the electronic patient record system.

The team has also co‑produced a ‘my life’ booklet with patients and staff. This resource enables patients to share personal information, preferences and aspects of their history that are important to them, supporting staff to deliver more individualised and responsive care. The booklet has been produced in both standard and easy‑read formats and has also been translated into Polish to support accessibility for diverse patient groups.

Collectively, these initiatives demonstrate a clear commitment to continuous improvement, patient involvement and the creation of a therapeutic and culturally responsive environment.