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
• Environmental sustainability – sustainable development

We have not awarded this service a score for Well-led.

Find out about when we will not publish a key question score and what we look at when we assess Well-led.

The trust 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 to meet these.

The trust launched a new strategy in 2024, which was set to run until 2034. This strategy was centred on four main objectives: improving population health, delivering outstanding quality of care, supporting outstanding people, and ensuring the best use of resources. It also reflected the trust’s role within the wider healthcare system and aligned with key county-wide strategies, including the Integrated Care Partnership Strategy, the NHS Lincolnshire Joint Forward Plan, and the Lincolnshire Health and Wellbeing Strategy.

The trust’s vision was “to support people to live well in their communities.” This was supported by a set of core values that guided the delivery of high-quality, compassionate, and person-centred care: “we are kind, we are inclusive, we work together, our voice and actions matter, and we are always learning.”

These values underpinned how staff were expected to behave in their roles. Key behaviours included collaboration, curiosity, openness and honesty, compassion, fairness, courage, and recognising and celebrating success. Together, the vision and values established a clear framework for delivering effective, inclusive, and continuously improving care.

The board ensured that staff across the trust were actively involved in developing the vision, values, and strategic goals, and understood how their individual roles contributed to achieving them. Staff were provided with meaningful opportunities to engage in discussions about the trust’s direction and future plans, particularly during periods of change, development, and transformation. We observed positive examples of senior leaders supporting care group leaders and their teams to review and adapt their models of care, ensuring alignment with the trust’s overarching strategy.

We heard multiple positive examples of the trust’s values being lived in practice. During our assessment of service groups, staff spoke highly of the senior leadership team and described how they felt supported. Feedback from focus groups further reinforced this, with staff highlighting how the executive team consistently embodied the trust’s vision and values. Additionally, staff we engaged with during the well-led assessment clearly demonstrated a strong understanding of the trust’s vision and values through our discussions about their roles within the trust.

When carrying out our assessments of service groups across the trust it was evident that the vision and values had been embedded at a service level. Staff demonstrated clear and well-embedded vision and culture, underpinned by transparency, equity, equality, human rights, diversity, and inclusion. Staff at all levels understood the provider’s values and were able to describe how these were reflected in their day-to-day practice. Leaders communicated the vision effectively to frontline staff, ensuring there was a shared understanding of the service’s priorities and strategic direction.

The board had developed and implemented a clear strategy supported by an effective governance framework that promoted strong oversight and accountability. Services were organised into defined care groups with clear leadership arrangements, which supported the delivery of strategic priorities and clarified roles and responsibilities. Governance systems and processes had been strengthened, resulting in improved reporting to the board and greater consistency in how information was shared and reviewed. There were effective arrangements in place for oversight, including committees that enabled appropriate scrutiny, challenge and assurance. These processes supported leaders to have clear visibility of performance, risks and outcomes, and enabled timely action to drive improvement where required.

We reviewed how the trust had reorganised and realigned services into 10 care groups, with a revised governance structure. It was clear that the energy and focus amongst the care group leadership for the new framework was overwhelmingly positive. The revised governance structure gave care groups more accountability and had improved consistency in reporting to the board. The additional layer of oversight committees supported the care groups to have open and challenging conversations about not only the service they provided but also the outcomes for patients. In addition, the realignment in to care groups, allowed each care group to develop their own strategies which had been aligned the trust strategy and vision.

The non-executive directors spoke of a strong shared direction within the trust, supported by visible and engaged senior leadership which supported a consistent understanding of organisational priorities and helped reinforce strategic objectives across the trust. The boards chair was identified as playing a key role in maintaining this alignment by facilitating focused and effective discussion. They described the trust culture as values driven, emphasising openness, transparency and collaboration.

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.

The trust performed well in the 2025 NHS Staff Survey. The survey took place in Oct-Nov 2025. A total of 1,782 staff at the trust responded with a response rate of 59% (higher than the benchmark group average of 52%). Questions on compassionate leadership, flexible working, work-life balance, line management and stressors were responded to positively.

The trust took part in the NHSE Culture of Care programme for mental health wards to improve the experience of both patients and staff on mental health inpatient wards. The programme focused on improving staff wellbeing and psychological safety, relational, trauma-informed, person-centred care and inclusion of lived experience. The work was built into existing ward-based quality improvement activities, focusing on practical changes within teams. This included improving communication (such as safety huddles), strengthening supervision and staff support, and making ward environments more trauma-informed and suitable for different needs. Staff also received training in key areas like relational care and risk assessment. Executive and clinical leaders supported programme deliverythrough regular reflection and oversight. Many staff we spoke with felt psychologically safe to raise concerns.

The medicines optimisation (MO) strategy had been developed with staff input and was in line with the trust’s strategic aims with an additional priority of medicines safety. Regular 1:1 and appraisals aligned individuals’ goals in line with the strategy. The team worked to clinical pharmacy standards, and this was measured by performance metrics which were shared monthly with staff and included in a medicine’s optimisation & safety quarterly report, the first of which was presented at quality committee in April 2026 and then onward to the trusts board.

We heard of good systems of communication about medicines across the trust, such as pharmacy bulletins which highlighted important medicines related information, current supply issues and lessons learnt from medication errors. Pharmacists were embedded within care groups such as perinatal services and older people’s services. There was good oversight of the medicines supply by a third-party provider and staff told us that medicines were available when people needed them.

Patient partners and people with lived and learnt experiences regularly presented at board meetings, ensuring that senior leaders heard their perspectives. The trust had inclusive and flexible engagement methods to support patient engagement. These included pre-recorded videos, private sessions with senior leaders and face to face meetings.

Feedback from system partners highlighted the positive and constructive relationship with the trust, characterised by openness, transparency, and a willingness to engage with challenge. They reported that the trust was responsive to inspections of their services and committed to continuous improvement, and they had fostered a constructive environment for addressing challenges.

The trust had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embody the culture and values of their workforce and organisation. They had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

We observed the trust virtual board meetings, the council of governor’s meetings and reviewed minutes of governance and oversight meetings. In all our observations we saw leaders acting with integrity, credibility and respect. Board papers were available in advance and following meetings subtitled recordings of the meetings could be accessed. The trust had also produced a glossary which was available alongside their board papers providing a full explanation of some of the terms used.

The trust’s board comprised of 7 executive directors and 6 non-executive directors, including the trust’s chair. A council of 18 governors was also in place. Most executive directors and NEDs had been working for the organisation for many years with significant organisational history. The chief medical officer was the newest member of the board who joined in 2025. Two NEDS had been successfully recruited to join the board and were currently in the on boarding process. The NEDs had backgrounds in healthcare, change management, finances, science and research.

The executive team held a wide range portfolios, including quality, effectiveness, risk management, people, finance, procurement and transformation. Members of the board were positive about the newly appointed medical director, recognising the additional energy and leadership they had brought. The NEDs demonstrated their understanding of the trusts risk, finances and performance. Board papers, minutes of trust committees and interviews showed that the NEDs provided robust challenge and supported the executive team to drive improvements at pace, when required. They encouraged the board to seek assurance rather than reassurance, ensuring that risk management and performance outcomes were aligned and supported the trust strategic objectives.

The council of governors met quarterly, with meetings open for staff and the public and alternating between face-to-face and virtual formats. Governors reported positive, open relationships with the board and NEDs and felt confident to challenge constructively. Observations of meetings confirmed they discharged their governance role effectively, contributing to strong oversight arrangements. It was clear when speaking to the NED’s that they worked closely with the council of governors and that they were accountable to them.

Leaders at every level were visible and led by example, modelling inclusive behaviours. The trust had developed a positive, open culture where staff felt confident to speak up and be heard. There were clear mechanisms in place to ensure these were listened to and acted upon. Senior leaders were aware of behaviours that could undermine a positive culture or impact on the quality of care and took timely and appropriate action to address concerns when they arose.

Staff described the leadership within pharmacy as stable, inclusive and supportive. Staff were supported to attend profession specific training to support them to develop their roles. Pharmacy staff working within other care groups such as peri-natal told us that senior leaders were accessible and supportive.

It was evident that leaders had the experience, capacity, capability and integrity to ensure that the trusts vision could be delivered and that risks were well managed. When risks were identified, leaders openly reported and shared these with stakeholders and implemented mitigation plans to manage them effectively.

Leaders demonstrated a strong understanding of service quality and performance priorities. They were supported to maintain these through ongoing development opportunities. There had been significant investment in leadership development at both board and senior levels within the trust, with a focus on creating psychological safety, encouraging constructive challenge, and strengthening organisational culture. These programmes ensured leaders had access to the support and development needed to be effective in their roles.

The trust had a strong culture of internal progression whilst recognising the importance of external recruitment. For senior leaders programmes such as the “aspiring chief executive” and NHS England’s “next director” scheme supported effective and inclusive succession planning, helping to build a diverse and sustainable leadership pipeline for the future. For frontline staff the trust had invested in 20 apprenticeships.

Active Bystander and Allyship training strengthened organisational culture and leadership. In addition, it supported an inclusive and accountable environment. The training equipped staff to recognise and challenge inappropriate behaviour, using a four-stage intervention model (notice, interpret, take responsibility, act). We heard that the training had improved confidence in speaking up, reduced barriers, and promoted openness.

Processes to ensure that senior leaders remained fit and proper for their roles were robust and effective, and aligned to the trust policy. We reviewed 7 board members personnel files and found that they were all compliant with the fit and proper persons requirements. The personnel folders demonstrated that the 7 leaders had the skills, knowledge, experience and integrity that they needed to have when they were appointed and this was reviewed annually. All folders had disclosure and barring service checks, references, mandatory training records and evidence of appraisals. Both the trust secretary and their deputy fully understood the process of the fit and proper person check.

The trust fostered a positive culture where people felt that they could speak up and that their voice will be heard.

The trust had established a positive, open culture where people felt able to speak up and be heard. This was supported by a strategic framework built around four pillars: accessible support, an open culture, accountable and engaged leadership, and building trust through action and feedback.

The trust had a strong Freedom To Speak Up (FTSU) framework, with the guardian closely linked to the board through an executive lead (the CEO) and a non‑executive FTSU champion. The guardian was supported in their role by a network of 15 trained FTSU champions from diverse services and staff networks. They acted as advocates and signposted staff rather than handling cases directly. The FTSU guardian and champions had strong links with the equality, diversity and inclusion lead and staff networks particularly the REACH (Race, Ethnicity and Cultural Heritage) network. This supported BAME British staff who raised a higher proportion of concerns at 15% compared to the workforce at 8 to 9%. We heard during the assessment, that some people, particularly those from Black and minority ethnic backgrounds, continue to feel hesitant about raising concerns.

Speaking‑up governance was scrutinised by the non‑executive champion, and the board reviewed activity quarterly through the audit committee and people committee. Quarterly and annual reports provided information on concerns raised, lessons learnt and recommended actions. The audit committee focused on the effectiveness of speaking‑up processes and staff confidence, reviewing data on case numbers, staff groups involved, issue types and escalation routes. The people committee received detailed analysis of emerging themes and cultural insights, triangulated with intelligence from people leaders and the chief nursing officer to identify wider workforce and wellbeing trends.

New staff were introduced to the FTSU guardian during induction and were provided with information on how to raise concerns.

The number of cases brought to the FTSU guardian each quarter showed an increasing trend from July 2024 to June 2025 but has stabilised since then. During the period 1 April 2023 to 31 December 2025 only 2 cases were raised anonymously and 1 person indicated detriment from speaking up.

A total of 133 FTSU cases were raised to the trust between 01 January 2025 to 31 December 2025. We noted that 58% involved a worker safety or wellbeing element, 14% involved a bullying or harassment element, or involved a patient safety or quality element or involved an element of inappropriate attitudes or behaviours. Positively, no one indicated that they suffered disadvantageous and/or demeaning treatment because of speaking up. Just 2% of the cases were raised anonymously which, along with the low rates of reported detriment, suggested that many staff felt comfortable to raise concerns to the guardian. We noted that when things had gone wrong, the trust ensured that people received a timely apology and were informed of the actions the trust would take to prevent reoccurrence.

The trust’s 2024–2025 FTSU annual report showed that staff who raised concerns were listened to, received responses, and saw lessons applied. Concerns about communication and tone within teams led to targeted interventions, including behaviour‑reset work, team workshops and clearer expectations around civility. Issues relating to rostering highlighted unintentional disadvantage for some staff, prompting reviews that resulted in fairer shift patterns, improved consultation, and better morale.

Several cases demonstrated managers’ uncertainty in handling concerns, which were addressed through coaching from the FTSU guardian and HR teams to build confidence and strengthen relational leadership. Staff also raised concerns about communication during change programmes, leading to earlier engagement, clearer messaging and greater acknowledgement of staff impact during restructures. Instances of inconsistent policy application prompted reviews and reminders to managers to apply policies fairly and transparently. Speaking up from staff with protected characteristics led to improved follow‑up processes, reinforcing the need for accessible feedback loops and tailored support. Overall, the report emphasised that speaking up continues to be a key driver of organisational learning, with the FTSU guardian ensuring each concern contributes to ongoing improvement.

The trust valued diversity in its workforce. They were working towards an inclusive and fair culture by improving equality and equity for people who work for them. Senior leaders recognised there was still more work to do.

Leaders acted to continually review and improve the culture of the organisation. They were committed to creating a supportive, inclusive and safe working environment where staffs’ wellbeing and equality were prioritised. They used data and a person-centred approach to workforce planning, wellbeing and equality, diversity and inclusion (EDI). All executive directors had a specific EDI objective in their annual appraisal to ensure they remained accountable and responsible for embedding EDI in all aspects of their role. The trust in 2025 presented their first combined annual report, integrating all their EDI reports into a single comprehensive report. This decision was made to create a more connected and effective approach to achieving their EDI goals.

We found robust governance structures were in place where equality, diversity and inclusion (EDI) were overseen. Working groups, staff networks, staff survey results and speaking up issues were agenda items from wards to board. The trust had an executive lead for EDI. EDI objectives had been embedded across the trust from leadership development, recruitment practices, staff wellbeing, and linked to patient’s care. Leaders heard from their staff about what mattered most and worked collaboratively with the staff networks to co-produce improvements and reflect lived experience and local needs.

The Patient and Carer Race Equality Framework (PCREF) is a mandatory framework for mental health Trusts in England to reduce racial inequalities in care. In Lincolnshire, this includes ethnic minority, Eastern European, and Gypsy, Roma and Traveller communities. The Chief Transformation Officer led PCREF, embedding it into business as usual, alongside the Equality Delivery System and wider Health Inequalities work, while working with partners to implement and monitor progress.

The PCREF action plan outlined actions taken by the trust, including ethnicity-based data reporting, improved community engagement, policy and training reviews, and participation in a national network to share best practice. The plan included 18 actions within a self-assessment checklist under ongoing review: 3 on governance and leadership, 6 on policy and practice, 2 on legislative compliance, and 7 on data and information. However, it was unclear when the plan was published or the timeframe it covered. It also lacked defined milestones, completion dates, and review points, limiting transparency and the ability to assess progress.

Leaders recognised that some staff, especially those from minority backgrounds faced inequalities, particularly around race and inclusion. To address this, they had introduced development programmes for internationally educated nurses and other underrepresented staff to support career progression. Initiatives like the “Be the Face of Change” campaign and staff-led forums helped create a safer environment where staff felt more comfortable speaking up.

Leaders were taking action to tackle bullying, harassment, and poor behaviour, especially where it affected staff with protected characteristics more than others. Reports of bullying remained in some staff groups. However, continued emphasis on informal resolution and the application of “Just Culture” principles had led to a significant decrease in the number of formal cases, suggesting a positive shift towards more open and constructive resolution processes. In addition, the staff survey highlighted a positive decline for question 14 “The last time you experienced harassment, bullying or abuse at work, did you or a colleague report it?”. The result improved to match the best in the benchmark group between 2024 and 2025. This outcome suggests staff felt increasingly safe to report these experiences and they felt appropriate action will be taken.

Workforce Race Equality Standard (WRES) is a mandatory framework to ensure that employees from black and minority ethnic (BAME) backgrounds are treated fairly and have equal access to career opportunities. WRES data is a set of 9 measures or indicators of equality in the workforce. Each measure compared white and BAME experiences. The trusts WRES data highlighted a potentially problematic culture at the trust in which BME staff experienced unfair or even discriminatory treatment. BME representation among the workforce (indicator 1) and the board (indicator 9) is lower than at most NHS trusts. This reflected the low diversity of the local population, making it particularly important that the trust had fair and inclusive recruitment practices to ensure the trust was culturally competent and could effectively meet the needs of all patients. However, white candidates were 2.4 times more likely to be appointed after shortlisting (indicator 2), a disparity that has grown from 1.6 in 2021.

The experiences of the BME staff at the trust in 2024/25 were found to be poor: BME staff were 3.5 times more likely to enter formal disciplinary processes (indicator 3) and BME staff experienced disproportionately more harassment, bullying and abuse than their white colleagues (indicators 5-6). Particularly concerningly, the percentage of BME staff who said they experienced discrimination from a manager, team leader or other colleagues was the highest of all trusts in the sector (indicator 8) and considerably higher than previously at the trust.

More positively, roughly equal proportions of BME and white staff at the trust undertook non-mandatory training and CPD in 2024/25 (indicator 4) and both groups were higher than average for the percentage that believed the organisation provided equal opportunities for career progression or promotion (indicator 7).

7.7% of LPFT’s board in 2024/25 was BME compared to a sector median of 21.1%, placing it in the lowest quartile (least diverse) of all trusts and ICBs nationally. However, a more positive finding was the board was only slightly less representative (-3.3 percentage points) than the ethnic makeup of the overall workforce at the trust. However, the low level of board diversity reflects the diversity of the local population.

The trust’s 2024/25 Annual Equality Report showed that all 2024-2025 actions for race equality were completed. It also highlighted the initiatives being put into place to improve race equality, including enhanced data monitoring, updated recruitment training, reciprocal mentoring, and a range of events. However, given the WRES findings the trust needs to be assured that the initiatives that they have in place are enough to improve the experiences of BME staff at the trust.

The trust showed a strong commitment to supporting disabled staff and those with additional needs. The introduction of the reasonable adjustments toolkit and wellbeing passport helped ensure support was personalised and consistent. Leaders developed managers skills in holding supportive conversations about disability, neurodiversity, and wellbeing, so staff could not only work effectively in their roles but be supported too. Flexible working options, including self-rostering, annualised hours and term-time contracts, were being expanded to support diverse staff needs and improve work–life balance.

The trust had robust processes for Equality and Impact Assessments (EIAs). This supported the trust to ensure that their services, policies and practices did not directly or indirectly discriminate against staff or service users. The board and senior leaders were responsible for the effective compliance of the completion of EIAs. The EDI team provided a quarterly report to the people and workforce advisory group to review compliance and quality of the EIAs, which fed into the people committee to provide assurance.

Staff engagement was strong and senior leaders used a range of methods to make sure voices were heard, especially from underrepresented groups. These included executive briefings, roadshows, podcasts, an anonymous “Ask Sarah” platform (a direct link to the CEO), and staff networks supported by senior leaders. These networks help shape policies, improve ways of working, and influenced key decisions. The LGBTQ+ staff network explained how after the supreme court ruling confirming that “sex” in the Equality Act 2010 meant biological sex, the CEO worked with them to understand what changes, if any, were needed to make sure patient care remained inclusive, met the individual patient needs and the law.

The trust did not have EDI champions. This decision was made following consultation. The trust was concerned that having champions in place would place the responsibility on a person to ensure that EDI was embedded and could become a ‘tick box’ role. Instead, the EDI team supported wellbeing champions to share learning more widely. Staff network representatives attended meetings and provided feedback to their teams. Not having EDI champions had not affected the trust collaborative working to produce/review policies and documents. For example, menopause, reasonable adjustments.

During our inspections of assessment service groups, we acknowledged EDI was embedded across the services, with training and processes in place to reduce discrimination and promote fairness. Leaders demonstrated a strong understanding and actively worked to address inequalities. Staff and patients at the Francis Willis unit were proud to share innovative initiatives such as a Cultural Café and participation in a national improvement project which helped strengthen cultural awareness and person-centred care.

The trust had 9 staff network groups which were active in the trust, with executive leads who engaged, promoted and advocated for them at board level. Regular meetings took place between the executive champions, network chairs and CEO. Feedback from the chairs of the staff networks indicated that staff networks were valued and influential mechanisms within the trust. The chairs consistently reported that they felt heard through established structures such as executive sponsorship, the council of staff networks, and direct access to senior leaders, with sponsors described as visible, approachable, and actively engaged. We heard how networks were engaged with policy development, cultural improvements, staff wellbeing, and external engagement, alongside providing peer support and appropriate escalation pathways for individual staffs when required.

The trust held a variety of EDI events, including the networking with PRIDE conference held at a university facilitated and attended by the trust, social care, charities, the police, fire service and a local school. The MAPLE (mental and physical lived experience) network ran a series of events for disability month. Similarly, the BAME staff network celebrated black history month. The women’s staff network introduced a system wide book club and tea break roulette focusing on bringing women together.

The chairs of the staff networks spoke positively about managerial support and the provision of protected time for network roles. Although challenges remain in achieving consistent engagement, particularly among patient-facing staff, due to staffs’ due diligence to continue to provide support for people who were using services. The awareness and visibility of networks was good, networks were promoted on the trust intranet, introduced to staff on induction and lanyards and badges were provided to pledge alliance to specific staff networks.

Leaders introduced wellbeing initiatives such as psychological support, safeguarding supervision, and better absence management with early intervention. Workplace wellbeing support was in place through wellbeing passports for staff and reasonable adjustment toolkits to support individuals’ staff’s needs. Staff mental health was supported by a pathway into talking therapies enabling quicker access. Specialist support was also offered for menopauses, domestic abuse and financial wellbeing. The introduction of the staff safety hub, in January 2026, provided an accessible system for staff to report concerns and access support, particularly in response to increasing incidents of violence, aggression and abuse. For example, post incident support. Increased reporting was viewed positively, reflecting improved psychological safety and confidence among staff to raise concerns.

Within the pharmacy team managers are very supportive of flexible working patterns and fully supported those requiring reasonable adjustments. We heard of excellent support offered to staff following a serious incident and that all staff involved were offered a de-brief.

Staff shared with us examples of where interpreters attended inpatient multi-disciplinary team (MDT) meetings to allow patients to have the opportunity to ask direct questions about their medicines rather than using language line. We heard of one example where a pharmacist was able to discuss the use of lithium and provide written information in Arabic.

There was no capacity for pharmacy staff to be able to attend community MDT especially for CAMHS and LD although there was an awareness of the importance of the STOMP (stopping over medication of people with a learning disability and autism) agenda.

Senior leaders evidenced their commitment to the wellbeing of staff throughout the transfer of undertakings (Protection of Employment) Regulations 2006 (TUPE) for agreed changes to the Section 75 (S75) mental health social care agreement. The trust had a structured inclusive approach which played a key role in support the wellbeing of staff thought the process. They prioritised, open communication, regular engagement opportunities and offered tailored support to individual. In doing this it helped reduce uncertainty and build trust during a process of change. Staff felt heard, valued and supported.

The trust 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 acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

The trust had a strong governance framework in place to ensure quality, safety, and effective decision-making. It used a range of tools such as dashboards, patient feedback, safety meetings, and executive walkabouts to gain real-time insight and improve oversight.

Governance at the board level had been strengthened by focussing on the risk register and key strategic risks. Committee meetings encouraged open discussion and challenge with an aim to provide clear assurance not just reassurance. Following an external review of the trust governance processes, committee meetings were held less frequently. This supported leaders to have a more efficient and effective governance process with clarity of roles and responsibilities; better reporting quality and escalation of risks were improved.

Following the trust’s well-led self-assessment against the new NHSE and CQC guidance, it was identified that excessive information was being escalated to senior committees, resulting in lengthy agendas and limited early oversight by the chief nursing officer and care group directors. In response, the trust revised its governance structure to improve efficiency, introducing clearer reporting lines, new committees such as the healthy population committee and mental health legislation committee, and additional oversight groups at care group level. These changes reduced duplication, improved decision-making, and ensured issues were addressed at the appropriate level. Senior leaders reported greater autonomy and more time to implement improvements, with committee cycles enabling them to provide assurance, rather than reassurance, to board committees.

The trust had moved from a divisional structure to care groups and service lines to strengthen leadership, accountability and increase workforce effectiveness. The new model reduced management layers, improving communication, staff engagement and opportunities for innovation. Care groups were led by directors of operations, supported by quality improvement, assurance and data analysts, with staff highlighting the benefit of having dedicated analytical support. However, some non-nursing staff felt the streamlined structure reduced their management representation and professional visibility.

The trust maintained a clear position that quality and finance were closely linked, ensuring that financial decision-making did not compromise patient safety or regulatory standards while still delivering the agreed financial plan. To support this, defined “red lines” were in place, supported by processes such as quality and equality impact assessments (QEIA) panels and ongoing reviews of these decisions. For example, a proposed reduction in peer support services was stopped due to risks to care quality. Quality impacts were monitored via the quality committee and triangulated with finance and performance data. Additionally, the “Living Within Our Means” programme aimed to balance financial sustainability with high-quality care delivery by reducing inefficiencies, minimising workforce redundancies, and improving productivity to manage demand.

During our service-level assessments, we found wards had sufficient staffing to provide safe care and treatment. Benchmarking showed stable performance compared with peer organisations, alongside reduced agency use and improved workforce stability. The trust's nursing workforce was particularly strong, with 85% of nursing staff being qualified, outperforming national comparators (February 2026). Most wards consistently achieved staffing fill rates above 90% for both registered nurses and healthcare assistants. The main exceptions were Langworth Ward and the Francis Willis Unit, where staffing levels were below target over recent months. As a result, staffing remained a significant risk within the board assurance framework and care group risk registers, ensuring ongoing Board oversight and robust monitoring of improvement actions.

The trust’s February 2026, safe staffing review found compliance with key national staffing standards, with most wards having appropriate staffing levels and safe systems in place. Some workforce challenges remained due to sickness and training commitments. The review identified a need for increased staffing on the newly opened Havenside Ward because of its size, higher patient acuity and observation requirements. The board approved the recommended increase.

The Integrated Performance Report (IPR) that was seen by the board in April 2026 highlighted that the staffing vacancies had reduced from 10.55% to 9.7% against a national average of 17.3%. Sickness rates remained stable at 5.9% which was below the regional benchmarked average of 6.9%. This placed the trust second best in its peer group. The use of agency staff had reduced across most areas, with no agency use in non-clinical roles. This had resulted in a reduced agency spend of £0.47m below plan.

The trust met the formal reporting and structural requirements of the guardian of safe working hours framework. At the time of the assessment there were 47 resident doctors across all grades supported by 4 locum posts. The trust had a guardian of safe working hours, who reported quarterly to the board, for oversight and escalation processes if required. Whilst there were gaps in the rotas reported across all grades of doctors the gaps were mitigated using locums. All out of hour’s shifts had been covered. Junior doctor forums were held bimonthly and chaired by the guardian of safe working hours. This forum played a pivotal role in the changes to doctor handovers ensure that essential information was not missed. The board were assured that systems were effective, doctors are supported, and patient safety was maintained.

The trust met the requirements of the guardian of safe working hours framework. Rota gaps were covered through locum staff, ensuring all out-of-hours shifts were filled, while junior doctor forums led to improvements in handovers. The board received regular assurance that doctors were supported and patient safety was maintained.

The 2025 GMC Trainee Survey was positive, with workload the only above-average indicator at trust level. Psychiatry F1 trainees also reported above-average results for reporting systems, teamwork, supportive environments, induction and rota design.

The trust was placed in segment 3 under the NHS Oversight Framework (Q3 2025/26), largely due to its financial position, despite performance that would otherwise place it in segment 1 or 2. It performed strongly in areas including dementia diagnosis, post-discharge follow-up, perinatal services, eating disorders, and urgent children and young people’s pathways. However, challenges remained in routine children and young people waiting times, physical health checks for people with severe mental illness, and timely face-to-face crisis assessments. Ongoing pressures included out-of-area placements and extended lengths of stay. The trust demonstrated strong outcomes in effectiveness, experience, people and workforce, but further improvement was needed in patient safety, finance and productivity.

Our assessment of financial governance found the trust had a strong history of financial performance, delivering at least breakeven positions between 2017/18 and 2024/25. In 2025/26, it achieved its planned deficit position which resulted in an additional receipt of £1.6m deficit funding from NHSE., and delivered £11.5m in savings, although almost half were non-recurrent. The trust maintained healthy cash reserves of around £40m but ended the year with an underlying deficit of £12.3m.

For 2026/27, the trust set a balanced financial plan reliant on delivering £12m in savings and identified risks around achieving these targets. To support long-term sustainability, it implemented the ‘Living Within Our Means’ programme, with strengthened governance arrangements and executive oversight. Significant investment in the estate included the successful £36m Havenside Ward development, completed on time and within budget. However, reduced capital funding may limit the trust’s ability to address backlog maintenance and infrastructure needs. While the medium-term financial plan aims for breakeven by 2027/28, this remains dependent on delivering substantial future savings.

Although the trust has a well-defined programme to address financial sustainability, which is appropriately balanced against quality and safety considerations, and a clearly articulated board position on safety red lines, it cannot be assured that the financial shortfall will not increase or adversely impact the quality of care.

The trust’s risk management was governed by the reporting and management of risk policy, which had recently been updated to align with the move from operational divisions to care groups and service lines. The trust assessed its strategic risks through a board assurance framework complemented by the Organisational Risk Register (ORR). As of May 2026, the ORR identified 26 key risks, including three held on a private register, alongside a further 76 risks managed at care group, service line, and corporate levels. A comprehensive thematic review of the ORR was completed in early 2026 to ensure it reflected the most critical strategic priorities. The board had agreed its target risk appetite for each risk domain.

The trust had well-developed governance and risk management arrangements aligned to its strategic priorities. The board assurance framework (BAF) was robust, regularly reviewed, and provided effective oversight through board committees and the audit and risk Committee. Following feedback from NEDs, the BAF was enhanced to include more qualitative information alongside performance data, improving understanding of risk.

The BAF identified 12 strategic risks across the trust’s four key pillars: healthy population, best use of resources, outstanding people, and outstanding quality. Three risks were rated as extreme and nine as high. Nine of the 12 risks had reduced from their inherent score, demonstrating the effectiveness of controls and mitigating actions. However, risks relating to financial sustainability, digital infrastructure, and workforce capability remained at an extreme level despite mitigation measures.

The trust submits to two NHS data collections measured in the Data Quality Maturity Index (DQMI): the improving access to psychological therapies dataset and the mental health services dataset. In the month of January 2026 (the latest available data), the trust’s DQMI score was higher than the national score in both datasets. The trust’s overall DQMI was 97.0%, which was higher than the overall national average of 71.3%. This suggests that there were good data management processes in place at the trust.

The trust had implemented a patient safety incident response framework (PSIRF) policy in March 2024, setting out its approach to incident management and promoting a just culture focused on fairness, learning and staff support. The policy is due for review in April 2027.

The trust continued to strengthen PSIRF governance, including enhanced oversight of incident data and improved monitoring of actions and learning. Further work was underway to better align learning from deaths, incident reporting and PSIRF processes to support more effective triangulation and organisational learning. Senior leaders advised that a new electronic analytics system would support this development, although it was still in the early stages of implementation.

The trust had effective governance arrangements to meet its statutory duties under the Mental Health Act (MHA) and Mental Capacity Act (MCA). A revised governance framework introduced in January 2026 strengthened oversight through new operational forums, oversight groups and the mental health legislation committee, improving accountability, escalation processes and monitoring of compliance.

Strong collaboration between internal teams and external partners supported legal compliance, clinical practice and human rights considerations. Established audit and review processes helped ensure the quality and legality of detention documentation, although operational pressures continued to create challenges in maintaining documentation timelines. Staff demonstrated a good understanding of MHA and MCA requirements, supported by training and case-based learning.

The trust had strong governance arrangements for restrictive interventions, with oversight provided through dedicated groups reporting to the mental health legislation committee. Following enforcement action on acute wards, weekly safety review panels were introduced to review rapid tranquillisation incidents, promoting learning and contributing to improved compliance at follow-up inspection. These panels have been retained as an ongoing quality and safety measure.

The reducing restrictive practice team provided training, clinical support, incident support and debriefs for staff and patients. Restrictive interventions have reduced significantly since April 2024, with February 2026 recording the lowest levels since May 2023. Patient partners also played a key role in reducing restrictive practices by developing a powerful training film based on lived experience, which is now used in all restrictive intervention training.

The pharmacy team had clear workforce plans based on a demand and capacity model, although support for specialist community mental health teams in learning disabilities and CAMHS was limited. The team played a key role in the Trust’s digital transformation programme, but staffing pressures, including sickness, long-term absence and vacancies, reduced opportunities to provide discharge counselling. This was recognised as an area for improvement and performance had been improving since autumn 2025.

Medicines optimisation was well governed through the medicine’s optimisation group and drug and therapeutics group, with effective oversight of medicines safety, including controlled drugs. The medicines safety officer also contributed to patient safety incident reviews to ensure medicines-related learning was captured and acted upon.

The trust understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

Leaders at the trust were invested and had built positive working alliances with integrated care boards, place-based partnerships, provider collaboratives and other relevant forums, including primary and social care partners.

Due to the reconfiguration of the integrated care boards the trust was now aligned with Derbyshire and Nottinghamshire (DLN) in the integrated care board cluster. The newly formed cluster was in its infancy and created some uncertainty for the trust. However, the cluster did have a strategic plan for 2026-2031 focusing on improving population health, reducing inequalities, and transitioning from traditional commissioning to a "should cost/should deliver" model.

The trust demonstrated a clear commitment to collaboration and system leadership. The trust led the Lincolnshire mental health, dementia, learning disability and autism alliance, bringing together partners from health, social care, policing and the voluntary, community, faith and social enterprise (VCFSE) sector to address complex challenges that required a coordinated, multi-agency response. This approach supported the design and delivery of more joined-up services, enabling people of all ages to access seamless, person-centred care within their local communities.

The trust played a key role in embedding co‑production at both organisational and system levels, aligning activity with strategic objectives and governance processes. It co‑facilitated the mental health co‑production network with Shine Lincolnshire; a health and wellbeing charity focused on strengthening communities and improving access to support. Together, they contributed to ICS structures and transformation programmes.

The council of lived and learnt experience, established under the quality committee, ensured lived experience informed board‑level decision‑making. Over 120 individuals contributed to co‑produced system statements, supported by a diverse network across multiple services. People with lived experience also influenced funding decisions for community and suicide prevention initiatives and were involved in recruitment panels, embedding co‑production within core processes. This approach was recognised across the ICS as good practice, demonstrating stronger collaboration, improved governance, and meaningful influence on service design, delivery, and evaluation.

The trust worked with partners to deliver the NHS long term plan for mental health, using national investment to improve access, quality and outcomes, and strengthen parity between mental and physical health. Joint planning and shared insight supported system-wide improvement and reduced variation.

The trust continued to play a key role in delivering large-scale transformation programmes, including the community mental health transformation programme and new children and young people’s mental health initiatives. These programmes were co-developed with stakeholders and focused on creating integrated pathways that improved access and delivered more proactive, preventative care closer to home.

The trust had a mental health urgent assessment centre (MHUAC) based at the local acute hospital site. The MHUAC provided a waiting room and three clinical assessment rooms. The centre enabled decision making for care and treatment away from the emergency department setting, in a more therapeutic environment. It had been set up to assess and manage the needs of service users, providing an easy to access service that provided timely assessment for people suffering from a mental health crisis. The centre accepted people over the age of 18 via walk-ins and referrals from the ambulance service and police, and/or diversions from the ED. Children could also access the centre by referrals from the ambulance service and/or diversions from the ED.

The trust led the community mental health transformation programme for adults and older adults to deliver neighbourhood health, improve outcomes, reduce inequalities, and ease pressure on acute services by delivering more person-centred, efficient care. Working with stakeholders and using population health data, it developed a neighbourhood model aligned with primary care networks. This integrated multidisciplinary clinical teams with social prescribing, peer support, and community connectors. Key achievements included 15 Mental Health & Wellbeing Hubs, 25 Night Light Cafés offering out-of-hours crisis support, and a digital platform providing virtual resources.

The trust worked collaboratively with Lincolnshire ICB commissioners to establish the night light cafes and twilight cafes (for young people). The trust worked closely with the VCFSE who delivered the service. Night light cafes delivered high impact, low-cost crisis prevention and reduced the demand on the NHS and emergency services whilst also improving mental health outcomes and social connections. The feedback from people who had used this service was very positive. 100% of people felt safe using the service and 81% felt that their mental health improved following their attendance. In the last year there had been 10615 referrals for the night light cafes, 169 people were diverted from accident and emergency departments and 165 from crisis teams. This led to a 71% reduction in local crisis referrals. 20 families per month attended the twilight cafes, which resulted in a reduction of 57% referrals to CAMHS.

Social prescribing was integrated within the neighbourhood model and community pathway. Social prescribing enabled people to make positive changes in their lives within their community by linking people to activities, voluntary and community groups and public services. From January to March 2026 there had been 209 supported attendances, 193 onward referrals and 721 people signposted for ongoing support. To support sustainability across Lincolnshire VCFSE and the mental health and wellbeing community investment fund (MHWCIF) was launched in 2022. The aims of the investment fund were to support grass root organisations to deliver and test out innovative ideas in response to the local populations needs. From 2024 to 2025 there had been 5000 participants, involved in 45 projects. This led to reduced isolation for people and increased confidence and wellbeing.

A community hub model was in place in Lincolnshire consisted of both fixed hub locations in areas with a higher density of population and satellite provisions to reach more rural communities. Community connectors helped manage activities in the hubs and connected people to organisations and groups within the neighbourhood model. The activities included but not limited to, wellbeing, older adult, dementia, young adult and veteran support, financial and employment support. In 2024 there were 72,000 attendances. Throughout 2025, 1,071 hours of the trust’s activity was delivered from a community hub and 1,058 appointments. From 12 January 2026 to 26 February 2026, 343 hours of activity and 421 appointments had been recorded as being delivered at the hub this is double that of the year before.

The trust’s collaborative work extended beyond the local system. The trust sits within the East Midlands provider collaborative which works in partnership with eight other NHS and independent sector providers of secure care services. The trust worked alongside providers and commissioners to deliver specialist services, including forensic, CAMHS and adult eating disorder provision, promoting consistency, shared learning and continuous improvement across organisational boundaries. In addition, the trust is the lead provider for the Midlands Op Courage veterans’ mental health and wellbeing service, coordinating a network of NHS, independent and voluntary sector partners to deliver a cohesive and high-quality service for veterans and their families.

The trust continued to strengthen integrated approaches to support people with complex and vulnerable needs. This included partnership delivery of criminal justice liaison and diversion services with the RECONNECT programme, helping to ensure continuity of care and support for individuals in contact with or leaving the criminal justice system.

In addition, the trust was a lead partner and provided strategic leadership and influence across key priority areas, including the following strategies for Lincolnshire, dementia, a multi-agency suicide prevention strategy, and an all-age autism strategy. These initiatives were informed by shared intelligence and co-produced with partners and communities, supporting a proactive and preventative approach to care. The development of a new virtual autism hub further demonstrated the trust’s commitment to improving access to information and enabling people to navigate services more easily and receive timely support before and after diagnosis.

The trust had an established system in place and worked with external stakeholders to safeguard people. Through a combination of incident reporting systems, structured screening tools, and the centralised safeguarding hub, staff were supported to recognise risks early and take appropriate action. The safeguarding hub provided specialist advice and support, triage and oversight across all safeguarding public protection and mental capacity issues. The hub was supported by 165 safeguarding champions across the trust. The acted as a first point of contact within their teams, sharing best practice a, updates and guidance. The safeguarding hub ensured a multi-agency response to safeguarding when needed. Evidence from June 2025 to June 2026 highlighted high levels of organisational engagement, including over 19,000 contacts for safeguarding advice, 1,321 DASH (domestic abuse, stalking and 'honour'-based violence) risk assessments had been completed and graded. 307 MARAC (multi-agency risk assessment conference referrals), 99 multi agency prevent related information requests, 209 allegations against staff members and 155 deprivation of liberty safeguards (DoLS) applications. Overall, we found that the level of safeguarding activity shows a strong culture, with clear systems in place to protect service users and support ongoing learning across the organisation.

The trust demonstrated strong leadership oversight, governance, and a clear commitment to continuous improvement through a six-month (Aug 2025 to Jan 2026) analysis of complaints across the trust. A total of 113 complaints had been made, with 58 open and 55 closed, highlighting operational pressure and the need for continued oversight. Leaders showed a clear understanding of key risks through thematic analysis, identifying communication as the primary driver in 103 complaints, followed by patient care (43), staff behaviours (42), and access to services (41), demonstrating insight into both relational and operational factors affecting patient experience. The governance process used the data to identify where higher volumes of complaints had been reported to target improvements (Adult Community Mental Health 56 complaints and Adult Inpatient & Urgent Care 40 complaints).

Complaints were managed by a dedicated team with strong governance, ensuring consistent and timely responses, with complaints acknowledged within 24 hours. Although we heard there were some challenges due to process duplication and legacy systems. However, the team are focusing on early, local resolution to improve timeliness and reduce formal complaints whilst prioritising meaningful patient outcomes. Current resolution times average 60 days (median 63), with targets to reduce this to 45 days and resolve 30% of complaints within one week. Additional initiatives included a language charter to cut communication-related complaints by 20% and improved care planning to reduce complaints linked to unmet needs by 15%.

At the time of our assessment the community clozapine monitoring service had a lead pharmacy technician vacancy, but we heard of excellent teamwork across the pharmacy to cover the clinic sessions and maintain the service until recruitment can take place. This service had previously received a people’s award in 2023 for supporting service users but is currently lacking strategic pharmacy leadership.

We also heard of a project working with local GPs to ensure those patients receiving antipsychotic depots (long-acting injections) are reflected accurately within their electronic systems. A QI project within Grantham CMHT led to significant improvements in outcomes for the physical health monitoring of patients on long-acting depots, next steps are to extend the scope to other CMHTs.

The trust focussed on continuous learning, innovation and improvement across their organisation and the local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

A trust-wide initiative, ‘Releasing Time to Care: Living Within Our Means,’ was designed to improve operational efficiency while enhancing patient care. The programme aimed to reduce administrative tasks, streamline processes, and enable staff to maximise the time spent on direct clinical care. Senior leaders were proud of the progress that had been achieved, linking the success to the active engagement of clinical teams, operational leaders, and individuals with lived experience. They were able to evidence improvements across key workstreams, including the redesign of clinical documentation, alignment of policies with national frameworks, and the standardisation of needs assessment and care planning. Stakeholders had initially raised concerns about the reduction in management layers due to reducing the leadership capacity and the alignment between frontline services and senior leadership. However, they noted following this change that there had been improvements in the “golden thread” and more direct escalation routes to the board.

Key achievements included the consolidation of over 40 assessment documents into a single, streamlined template, and the introduction of a standardised clinical audit tool. These improvements supported more consistent and patient-centred practice across services. Alongside these developments, the implementation of the new RADAR system, and the forthcoming launch of a patient engagement portal, strengthened communication, enhanced reporting capabilities, and enabled more robust, data-driven decision-making. The RADAR system is an online platform designed to manage quality, compliance, and patient safety by centralising incident reporting, risk management, and clinical audits. The programme remained on track to deliver its objectives by March 2027. During on-site inspections, both senior leaders and staff spoke positively about the initiative and reported that they were already seeing improvements in practice and patient care outcomes.

The trust purchased and built an integrated digital system, RADAR to support them to manage incidents, risk, audits and actions plans within a single platform. The system when fully rolled out and embedded across the trust will allow staff to record and track key information, improving accuracy and visibility of data. Senior leaders spoke highly of this system and were clear that it will support them to identify trends, highlight risks and support informed decision making. In addition, it will strengthen accountability and drive continuous improvement. However, this system is in its infancy so the trust could not provide meaningful data and outcomes during this assessment.

Following previous concerns regarding the safe and legal use of rapid tranquillisation, there was evidence of a sustained change in practice and culture with the prescribing and monitoring of rapid tranquilisation, with an overall reduction in use. RT is medication used by intramuscular (IM) injection to calm or lightly sedate a patient to reduce the risk to themselves and/or others by reducing agitation or aggression. People given rapid tranquilisation need to be monitored carefully after administration. Recent figures showed compliance of 100% with the legal consent to treat (CTT) paperwork. Work was being completed to understand the barriers to improving the compliance with monitoring of physical health checks or soft signs where physical observations are declined, or not possible, post RT administration. There was no evidence that there had been any patient harm where monitoring had failed to be completed. A specific RT component had been added to annual staff training, but overall compliance of medicines training remained at 83% in April 2026 with annual competency assessments of nurses at 73%. A digital app was soon to be launched to allow the monitoring of physical health post administration to be easier for staff.

High dose antipsychotic therapy (HDAT) when a patient required a total daily dose of antipsychotic medicine that exceeded the normal recommended dose which can lead to an increase in side effects. It is important if HDAT is used that patients had enhanced physical monitoring. Compliance was established as good within the inpatient setting, but a recent QI project examined the introduction of face-to-face community HDAT clinics by pharmacy technicians. The project demonstrated improvements in patient safety and outcomes and reduced the health disparities and won an award from the College of Mental Health Pharmacy. Work is ongoing within the Trust to establish the capacity to continue with these clinics.

Overall, the trust demonstrated a clear commitment to continuous quality improvement. Senior leaders actively promoted quality improvement (QI) initiatives by providing strong leadership, support, and engagement with both staff and patients. Staff were encouraged to participate in QI through initiatives such as learning forums, safety bulletins, and leadership engagement opportunities. A dedicated QI lead supported teams through coaching and facilitated engagement with quality improvement processes.

However, further work was required to ensure that a consistent QI model was fully embedded across the trust. While QI was well established at a senior level, it was not yet fully integrated throughout the organisation, and the “golden thread” from ward to board was not consistently evident. For example, QI training was not included as part of the staff induction process. This was a missed opportunity to embed a culture of quality improvement from the very start of employees’ careers within the trust.

Co-production was fully embedded across the inpatient services. People felt heard, and the usual hierarchy was not apparent, as everyone was treated as equal partners and valued contributors to improving services. The trust had delivered over 30 quality improvement projects involving patient partners. The trust actively listened to patients to understand their experiences, rather than simply collecting feedback. This was supported by the introduction of the every voice guardian role (patient equivalent of freedom to speak up), and patient partners which enabled patients to raise concerns and escalate issues directly to the chief nursing officer, directors of nursing and the board. Patient partners felt heard, valued, and able to influence outcomes, demonstrating the positive impact of this approach. The trust actively employed 14 patient partners. Patient partners are people who currently or had received care and treatment from different services within the trust. They were supported by the every voice guardian. The every voice guardian and patient partners were valued highly throughout the trust by patients and staff alike.

There were a range of formal structures supported by patient and carer involvement which ensured that their input was embedded. These included, mini every voice, carers council, council of lived and learnt experience and various steering group and governance committees. In addition, the patient voice was incorporated into governance through mechanisms such as patient councils, quality committees, and patient partner engagement. The introduction of the council of lived and learnt experience strengthened engagement by their commitment and participation in workshops, policy development and task and finish groups. Feedback from patient partners and the lived and learnt council were overwhelmingly positive. They felt truly heard and supported by senior leaders. We heard comments like, “the every voice guardian is a legend, we couldn’t do our role without her,” “when we come to meetings at HQ we are welcomed by everyone,” “I like to challenge senior leaders, and they welcome this and thank me for raising issues they hadn’t thought of. They always then support us to solve the issue.”

Patient partners had been trained in quality improvement methodologies and were supported to contribute fully with service development. Patient feedback has directly informed improvements across services, including the development of the co-produced ‘10 ward round standards’, which have strengthened patient involvement, choice and personalised care by ensuring patients are prepared, present and central to decision-making when attending ward round. Patient partners designed and wrote “what I wish I knew before I came into hospital” which was given to people when they were admitted to hospital to reduce anxieties and explain the layout of the wards, some essential rules and staff roles. In addition, patient-led initiatives such as the “come dine with us” project have resulted in measurable improvements to the inpatient dining experience, including enhanced food choice, accessibility, dining environments supported by clear, patient-derived recommendations and ongoing assurance mechanisms. Following feedback from patients about how they could provide feedback about their care and experiences, the patient partners devised and implemented the ‘Every Voice App’ with the help of the digital team. The app enabled patients to provide real-time feedback on their experiences, concerns and suggestions, with clear processes in place to ensure responses were timely and actions were taken. Opportunities such as the ‘dragon’s den’ panel further evidenced how patients are equal partners in designing and delivering service improvements. The dragon dens events were held across the trust; the panel was made up of members of the executive team and patient partners. Patients were supported to present their ideas for improvement which had been co-produced, to a panel which included patient partners and members of the board. An example included how to improve activities on the wards. They were then awarded money raised through supporting charitable funds events to implement the activities. These approaches evidenced that the patient voice was embedded, valued and instrumental in shaping safer, more responsive and person-centred care within the trust.

However, the role of the every voice guardian and patient partners were not as high profile in community services. Whilst this did not impact on co production and quality improvement plans led by patients in these services, it did mean that people did not have the opportunities or recognition across the trust. We do acknowledge that the trust was aware of this issue and were working to address it.

As part of the trust Patient Safety Incident Response Policy (PSIRF) and plan the trust had implemented a safety incident training package for all staff including the board and senior leaders. The training was split into two levels. Level one, ‘essential for patient safety’ which was delivered to all clinical and non-clinical staff during their induction and is repeated every 3 years. The board and senior leaders have a bespoke Level 1 training package. Level 2, ‘Access to practice’, is intended for those who have an interest in understanding more about patient safety. This training is optional for most except those in a designated role/team, such as those in an oversight role or in quality and safety teams.

In January 2026, the quality committee highlight and exception report and the learning from deaths report dated February 2026 reports showed that similar themes had been identified across learning from deaths, incidents and PSRIF, but these had not been fully aligned or brought together into one clear system. The trust recognised that they needed a more joined-up approach, where all learning was grouped under the same themes and brought together into a single patient safety report.

We reviewed 7 learning from deaths incidents and found that the trust had a well-established and structured learning from deaths process, with deaths reported via the electronic incident form, reviewed daily within care groups, and subject to initial patient safety reviews. Further oversight was provided through a weekly patient safety incident panel that determined if escalation was required. We found a clear governance framework in place from operational teams through to board level, supported by monthly mortality surveillance and thematic learning reviews, ensuring robust oversight and accountability. Learning was multidisciplinary and shared across divisions to avoid silo working, with thematic analysis used to identify recurring issues and drive system-wide improvements. When recommendations to improve practice were identified they were co-produced with frontline staff promoting a culture that promotes openness, duty of candour, and continuous learning. Families were involved throughout the process, with early engagement, ongoing communication, and opportunities to review draft reports, supported by a dedicated liaison role that enhanced transparency and trust. This approach has resulted in improvements to practice, including enhanced handovers, standardised communication processes, and environmental safety changes.

The trust had a research team that managed clinical research into mental health issues across the county. Research was aligned local and national priorities, with key areas of focus on, mental health across the lifespan, dementia dare and digital innovation and new models of care delivery. From April 2025 and May 2026 41 studies were active and 16 new studies had been opened. Research is supported by strong partnerships, particularly with higher education institutions, with 16 university‑sponsored studies contributing to the portfolio. In addition, the organisation supports workforce development through research, with four studies linked to academic qualifications, such as PhD programmes.

The trust understood any negative impact of their activities on the environment and strived to make a positive contribution in reducing it and support people to do the same.

Leaders had a clear vision for sustainability that was aligned to the trust’s overall strategy, the greener NHS agenda and national net zero commitments. Their vision was supported by the trust’s clinical and estates strategies, particularly through partnership working, delivering care closer to home, improving efficiency through transformation and rationalising the trust’s estate.

The board approved green plan (2022–2040) which provided clear strategic oversight. Executive leadership was clearly defined, with accountability for sustainability held at director level and supported by specialist estates, energy and sustainability leads. Progress against the objectives outlined in the plan were monitored in the quarterly review of the board assurance framework. This ensured responsibility for environmental impact is embedded at the highest level of decision-making.

Governance arrangements were in place to monitor progress, manage risk and provide assurance. A dedicated green plan committee oversaw the delivery of the green plan and action plan, with progress reported quarterly to the trust board, best use of resources committee and health & safety committee.

The trust was aware of key risks to achieving its net zero target by 2040. These include limited and uncertain funding, the need for clear long-term estates and clinical planning, the challenges of investing in leased properties, and ongoing emissions from business travel despite efforts to reduce them.

Leaders worked effectively with partners to deliver sustainability, recognising it cannot be achieved in isolation. The trust collaborated with system partners across estates, transport and procurement to support shared goals. Procurement processes aligned with the NHS sustainability standards, where environmental and social value had been considered in decisions. Leaders supported local sourcing where possible, benefiting both the environment and the local economy. For example, bread and dairy supplies were now procured from a regional supplier, with milk procured from local dairies.

The trust met all its statutory and NHS reporting requirements for environmental performance, including annual carbon emissions reporting. Data relating to energy, water, waste, business mileage and carbon emissions were collected monthly and reviewed regularly against an agreed baseline, enabling leaders to track performance and demonstrate impact.

Since 2021, the trust had invested in total £2,815,089 in sustainability initiatives to reduce carbon emissions from energy, waste, water and business travel. This included £215,806 being invested in improving loft insulation, increasing insulation depth to 200–400mm and reducing heat loss through roofs by up to 50%. Older gas boilers had been replaced at a cost of £384,220 installing 96% energy efficient boilers and reducing carbon emissions by 30–40%. In 2022, the Sycamore Unit transitioned from gas boilers to air source heat pumps, supported by £111,500 of public sector decarbonisation scheme funding within a £307,000 investment, delivering annual savings of c£2,500 and 50 tonnes of carbon. Since 2023, further investment in building management systems and energy metering has improved control of heating, hot water and ventilation, achieving annual energy and carbon savings of 10–15%.

The trust had recently opened a purpose-built new service, Havenside, which was the trust's first all-electric powered inpatient facility, including solar powered provision supporting its drive to delivering net zero services. To support sustainable travel and the use of electric vehicles the trust had installed 16 double charge points across seven trust sites.

The trust implemented an electronic prescribing and medicines administration (ePMA) system across all inpatient services. From a sustainability perspective, this had enabled medical staff to prescribe remotely, significantly reducing the need to travel between sites, particularly when on call or covering multiple locations. In addition, the move away from paper-based medication charts has substantially reduced paper consumption, contributing to a measurable reduction in the trust’s overall carbon footprint. In addition, the trust had minimised the use of CFC inhalers. Robust operating procedures minimised medicines waste and we heard of de-prescribing projects in conjunction with GPs to reduce polypharmacy.

The trust had implemented more sustainable models of care by delivering more services in the community and closer to people’s homes. The development of mental health crisis cafés and other community services had reduced travel for staff and patients, as well as journeys undertaken by the police, ambulance services and mental health transport providers. This had resulted in around 10,000 fewer inpatient bed days per year compared with 2019/20 and a reduction in secure patient transport journeys from 150 per month in 2019 to 65 per month in 2023.

We found a positive culture where sustainability is everyone’s responsibility. Leaders promoted engagement through communication, induction and training, encouraging staff to access net zero and environmental sustainability learning via an online platform.

Flexible and digital ways of working were actively supported, demonstrating a leadership culture that promoted wellbeing and reduced environmental impact.

To promote and support sustainability, the trust had recruited a voluntary network of ‘green champions. This enabled staff at all levels to contribute to local sustainability initiatives and support delivery of the trusts green plan in practice.