Lincolnshire Partnership NHS Foundation Trust

On this page

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

Effective - this means we looked for evidence that people’s care, treatment, and support achieved good outcomes and promoted a good quality of life, based on best available evidence. At our last assessment we rated effective as good. At this assessment, the rating has remained good.
Staff assessed the physical and mental health of all patients on admission. Staff provided a range of treatment and care for patients based on national guidance and best practice. The ward team had access to the full range of specialists required to meet the needs of patients on the ward. Staff from different disciplines worked together to benefit patients. Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Health Act Code of Practice and discharged these well.
Staff updated care plans when needs changed, but care records were not always consistently maintained or sufficiently person-centred to support effective ongoing review. This increased the risk of care not fully meeting individual needs or being consistently reviewed and updated.
Staff did not always complete Mental Health Act training in line with the provider’s requirements. This meant there was an increased risk that staff may not have had up-to-date knowledge to ensure full compliance with legal requirements under the Mental Health Act 1983.
 

This service scored 67 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure people’s care and treatment were effective because they did not always check and discuss people’s health, care, wellbeing, and communication needs with them.
Staff with the appropriate skills completed mental health assessments following admission. However, the level of detail were not always consistent across the service. Staff also assessed patients’ physical health needs shortly after admission, although recording of these assessments varied in quality.
Patients were involved in their assessments where possible, and most felt staff understood their needs. Patients had access to their care records, and staff supported engagement where required, including arranging interpreter support for patients whose first language was not English.
Staff used a range of clinical assessment tools risk assessments, physical health assessments, observation levels, capacity assessments, and outcome measures such as Health of the Nation Outcome Scales (HoNOS). However, the consistency and detail of assessment recording varied, especially in the Psychiatric Intensive Care (PICU) ward.
Staff developed care plans based on assessed needs and the plans were holistic. However, they were not always sufficiently detailed or consistently personalised. Care planning and documentation in the PICU ward were not always as detailed as expected. Staff updated care plans when needs changed, but care records were not always consistently maintained or sufficiently person-centred to support effective ongoing review.
This increased the risk of care not fully meeting individual needs or being consistently reviewed and updated. Leaders were aware of gaps in the quality and consistency of documentation and had begun taking steps to address this, although these improvements were not yet fully embedded.

We scored the service as 2. The evidence showed some shortfalls. Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Health Act Code of Practice and discharged these well, although there were some gaps in training completion which meant not all staff had received full relevant training.
Staff delivered a range of interventions appropriate for the patient group, in line with National Institute for Health and Care Excellence (NICE) guidance. These included medication management, occupational therapy-led activities designed to support recovery, improve functioning, and promote wellbeing.
Staff ensured patients had access to physical healthcare and referred patients to specialist services when required. Staff supported timely access to multidisciplinary input, including medical, nursing, occupational therapy, and pharmacy services, to meet patient needs.
The multidisciplinary team included or had access to the full range of professionals required to meet patient needs. Staff were experienced, qualified, and demonstrated the skills and knowledge required to deliver safe and effective care. Staff attended regular team meetings where they discussed clinical care, reflected on practice, and shared learning.
Staff participated in clinical audit, benchmarking, and quality improvement initiatives. For example, Patient Partners led a project following concerns about inpatient meals, which led to senior leaders experiencing mealtimes from a patient perspective and immediate improvements to portion sizes, alongside wider learning about patient experience and engagement.
Mental Health Act
Whilst staff were demonstrated a good awareness of the Mental Health Act 1983 (MHA), the level of compliance with MHA training was lower than expected. MHA training compliance was lower than other role essential training modules, with Level 1 at 66.1% and Level 2 at 72.6%. This level of compliance meant that a significant proportion of staff have not completed statutory MHA training, which is required to ensure understanding of legal frameworks, detention processes, and patient rights as set out in the MHA Code of Practice and Care Quality Commission expectations for safe staffing.
The provider outlined that it has implemented a targeted improvement programme to strengthen MHA training compliance, supported by governance oversight, senior leadership scrutiny, and monitoring through established quality assurance structures. While appropriate governance arrangements and oversight mechanisms were in place to monitor and address MHA training compliance, current completion rates meant that measures have not yet fully translated into consistent improvement in training uptake.
Staff had access to administrative support and legal advice regarding the MHA. Staff knew who the MHA administrators were and accessed local policies, procedures, and the Code of Practice when required.
Staff explained patients’ rights under the MHA in a way they could understand and repeated explanations when needed. Staff recorded these discussions appropriately. Staff ensured patients were informed of their rights to independent mental health advocacy and had access to advocacy services.
Staff supported patients to take Section 17 leave when authorised and ensured leave arrangements were followed appropriately. Staff requested second opinion appointed doctor (SOAD) input when required. Staff stored detention paperwork and associated records correctly and ensured they were accessible to relevant staff.
The service displayed information informing informal patients that they could leave the ward freely. Where applicable, care plans included reference to Section 117 aftercare arrangements for eligible patients.

We scored the service as 3. The evidence showed a good standard. The service worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.
Staff held regular and effective multidisciplinary team (MDT) meetings where they discussed patients’ needs, risks, and ongoing care plans. Staff communicated effectively within the team through structured shift handovers and huddles which supported continuity of care. We attended three MDT meetings and five ward rounds during the assessment. We observed that staff discussed patients’ needs, risks, and progress, and shared information to support ongoing care planning and treatment decisions.
Staff worked collaboratively with external partners to support ongoing care and discharge planning. Staff shared information appropriately with external teams, including community mental health teams, crisis services, care coordinators, GPs, and local authority services. Appropriate external teams, such as community liaison teams and adult social care teams were included in the ward rounds. A ward round is a meeting where the clinical team reviews a patient’s care and decides next steps together, often with the patient involved.
Staff ensured relevant information was available to all professionals involved in a patient’s care, which supported consistent care planning and delivery. Staff used MDT discussions, ward rounds, and handovers to ensure care plans reflected updated information and agreed actions were followed through.
Patients told us they felt different parts of their care worked well together and that they did not have to repeat their information multiple times.
Staff and leaders told us communication within the team was effective and supported safe care delivery. Staff also described positive working relationships with external partners. External parters also shared positive feedback regarding working with the staff at all the acute ward s for adults of working age and psychiatric intensive care unit.

We scored the service as 3. The evidence showed a good standard. The service supported people to manage their health and wellbeing to maximise their independence, choice, and control. The service supported people to live healthier lives and reduced their future needs for care and support.
Staff supported patients to improve their health and wellbeing, including participation in smoking cessation schemes, and support with substance misuse issues.
Staff encouraged and supported patients to take part to promote independence and positive lifestyle changes. Staff promoted healthy lifestyles through a structured activities timetable, which included activities designed to support healthy living and promote engagement. This included cooking sessions, access to a gym, and other therapeutic activities such as ‘Grow your own food’ that supported patients to make healthier choices around diet, physical activity, and daily routines.
Occupational therapy staff and activity staff worked together to deliver and adapt activities to meet individual needs. Staff understood that one approach did not suit all patients and offered alternative therapeutic activities for those who did not wish to engage in structured sessions.
Staff involved patients as much as possible in managing and monitoring their own health and wellbeing needs. Staff supported patients to attend physical health checks and worked with healthcare professionals to make reasonable adjustments where required to improve access to care.
Staff identified risks to patients’ health and wellbeing and supported early intervention to help prevent deterioration, including encouraging participation in structured and meaningful activities to support both physical and mental wellbeing.
Staff facilitated access to community-based activities where possible. In Ash Villa, staff used a pool car to support off-ward activities. However, this was often prioritised for clinical transport needs, which restricted opportunities for community engagement.
Patients told us they found activities helpful and engaging in supporting healthier lifestyles. For example, one patient said, “The activities help me get out of my room and feel better during the day,” and another told us, “It gives me something to focus on and keeps me active.”
Staff demonstrated commitment to maintaining a positive activity programme. However, provision was not consistently supported by sufficient or sustainable funding. One concern raised by staff was a lack of dedicated funding for activities and resources. Staff sourced some materials through donations or petty cash, and on occasions staff personally contributed to activity resources.
 

We scored the service as 3. The evidence showed a good standard. The service routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves.
The service routinely monitored people’s care and treatment to ensure outcomes were positive, consistent, and aligned with clinical expectations and the needs of people using the service. Staff used recognised and validated tools to assess, record, and review progress over time. Standardised outcome measures, including the Health of the Nation Outcome Scales (HoNOS) and physical health screening tools such as National Early Warning Score (NEWS) 2 were used appropriately to support consistent assessment of clinical presentation and to track changes in people’s health and wellbeing. These tools supported ongoing review of care and treatment effectiveness.
Staff also monitored clinical outcomes such as food and fluid intake where there was a risk of malnutrition or dehydration. In addition, staff supported patients to improve their quality of life through activities designed to promote engagement and wellbeing on the wards.
The service made effective use of digital systems to support monitoring and improve outcomes. Staff had timely access to electronic health records and used digital risk assessment tools. They also had access to dashboards for monitoring occupancy, incidents, and outcomes.
However, care records did not consistently evidence clear, individualised descriptions of expected or agreed outcomes with patients, and it was not always clear from documentation whether improvements in outcomes had been achieved over time.

We scored the service as 3. The evidence showed a good standard. The service told people about their rights around consent and respected these when delivering person-centered care and treatment.
Staff understood the importance of consent and supported patients to be involved in decisions about their care, support, and treatment. Staff took steps to ensure patients were informed and involved wherever possible.
Staff worked in line with relevant legislation, including the Mental Health Act and Mental Capacity Act 2005, and demonstrated understanding of decision-making requirements, including when capacity needed to be assessed.
Staff assessed capacity on a decision-specific basis and made best interest decisions where patients were assessed as lacking capacity. These decisions appropriately involved relevant professionals, family members, carers, or advocates and took account of patients’ wishes, feelings, culture, and personal history.
Advocacy services were available and involved where appropriate to support patient participation in decision-making.
Staff applied consent and capacity principles appropriately in practice. The main area for improvement related to consistency and completeness of MCA documentation. MCA assessments were not always consistently recorded for some detained patients where they would be expected. This meant documentation did not always clearly evidence that capacity had been considered for all relevant decisions.