Lincolnshire Partnership NHS Foundation Trust

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well led- This means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.
At our last assessment we rated well-led as inadequate. The service was in breach of legal regulation in relation to guidance at the service. The service has made improvements and is no longer in breach of regulations. At this assessment, the rating has changed to good.
Leaders had the skills, knowledge, and experience to perform their roles. Staff knew and understood the provider’s vision and values and how they applied to their team’s work. Staff felt respected, supported, and valued. Governance processes operate effectively. Performance and risk were managed well. Staff teams had access to the information they needed to provide safe and effective patient care. Staff collected and analyzed data about outcomes and performance. They used this to identify improvements. Leaders now demonstrated improvements in governance, particularly in relation to ensuring compliance with the Mental Health Act 1983. Staff now felt able to speak up, in line with the Freedom to Speak Up Policy and the support of Speak Up Guardian.
However, governance and management systems to ensure that information about risks, performance and outcomes were still not fully effective. As a result, we found gaps in how patients’ privacy was protected, personalisation of care plans and Mental Health Act training compliance.

This service scored 68 (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 3. The evidence showed a good standard. The service had a shared vision, strategy, and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.
There were a shared culture and direction across the service, underpinned by the provider’s values and a commitment to learning, collaboration and compassionate care.
Staff understood the provider’s vision and values and were able to describe how these shaped their day-to-day work. They reflected the organisation’s values of being kind, inclusive, working together, having a learning culture, and ensuring staff voice and actions matter in delivering person-centred care.
Staff demonstrated behaviours aligned with these values in practice, including working collaboratively across multidisciplinary teams, showing respect and consideration toward s patients, and approaching care with compassion, fairness, and openness. We saw staff working together to support patient care needs and sharing information across teams to support continuity of care.
Leaders promoted a culture of continuous learning and improvement, encouraging staff to reflect on practice and contribute ideas for improving care. Staff described feeling able to share feedback and contribute to discussions about service delivery and ongoing development, including within a context of service pressures.
We observed examples of staff working with curiosity and openness when responding to patient needs and using learning from incidents and daily practice to support improvements. There was also evidence of teams celebrating successes and sharing learning within and across wards.
 

We scored the service as 3. The evidence showed a good standard. The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organization. Leaders had the skills, knowledge, experience, and credibility to lead effectively. They did so with integrity, openness, and honesty.
Leaders at all levels demonstrated the skills, knowledge and experience required to manage and deliver the service effectively. They had a clear understanding of the clinical environment and were able to describe how teams were working to provide safe, high-quality care within the context of demand and resource pressures.
Leaders were visible within the service and approachable to both staff and patients. Staff described senior leaders as accessible, with regular presence on the wards and opportunities to raise issues or seek support when needed. This contributed to a sense of openness within teams.
We saw evidence of leaders modelling inclusive and professional behaviours, promoting a culture of collaboration, integrity, and openness. They demonstrated awareness of service risks and priorities and were able to explain how these were being managed in practice, including through multidisciplinary working and governance processes.
Leaders showed understanding of the importance of staff development and supported opportunities for learning and improvement within teams. Staff reported access to supervision and development opportunities, and leaders encouraged reflection and continuous learning.
 

We scored the service as 3. The evidence showed a good standard. The service fostered a positive culture where people could speak up and hear their voices.
The service fostered a positive culture where staff and patients felt able to speak up and share feedback. Patients and carers had opportunities to provide feedback on their care through established channels, and staff were aware of this feedback and used it to support service improvement where appropriate.
Managers and leaders had access to feedback from patients, carers and staff, and there was evidence that this was considered in team discussions and used to inform ongoing improvements within the service. Staff also described opportunities to contribute views about service delivery and raise issues within their teams.
Staff and patients had some opportunities to engage with senior leaders and provide feedback directly, supporting openness and visibility within the organisation.
Staff felt able to raise concerns and described a culture where feedback was listened to. Leaders were seen as approachable, and staff reported that concerns were usually responded to appropriately and escalated when needed. There was an overall sense that speaking up was encouraged, and staff were aware of routes available to raise concerns.
Most staff felt that where concerns were raised, leaders were responsive and sought to address issues through local processes, with learning shared where appropriate.
 

We scored the service as 3. The evidence showed a good standard. The service valued diversity in their workforce. They work toward an inclusive and fair culture by improving equality and equity for people who work for them.
The service demonstrated a well-developed approach to equality, diversity, and inclusion, supported by strong governance, staff networks and workforce monitoring.
The service demonstrated a clear organisational commitment to equality, diversity, and inclusion (EDI), supported by policies aligned with the Equality Act 2010 and the Public Sector Equality Duty. The provider promoted fairness, human rights, and the elimination of discrimination across both staff and service user groups.
Staff were aware of the organisation’s EDI framework and values, which emphasise respect, inclusion, and ensuring services are fair and accessible for all. The provider actively considered protected characteristics, including age, disability, race, sex, religion or belief, sexual orientation, pregnancy and maternity, and gender reassignment, within service planning and delivery.
The organisation had established staff networks to support inclusion and representation, including networks for ethnicity, LGBTQ+ staff, disability and lived experience, faith, neurodiversity, and other protected groups. These provided safe spaces for support, shared experience, and staff voice, contributing to a more inclusive workplace culture.
Equality Impact Assessments were embedded within organisational processes to assess the impact of policies and services on staff and patients, with action taken where risks of inequality were identified. Workforce reporting, including Workforce Race Equality Standard (WRES), Workforce Disability Equality Standard (WDES) and Gender Pay Gap analysis, supported monitoring of equality performance and identification of improvement areas.
Staff had access to flexible working arrangements and reasonable adjustments where required, enabling them to carry out their roles effectively. Managers were responsive in supporting these adjustments.
 

We scored the service 2. The evidence showed some shortfalls in governance assurance, with inconsistencies in care planning, risk assessments, and the identification of environmental risks through audit, meaning oversight of risk and quality was not always consistently assured.

We identified shortfalls in the quality and consistency of care planning and risk assessments, with some areas still in the process of improvement. In addition, environmental risks were not always consistently identified or fully captured through audit processes. This meant that governance assurance was not always fully consistent across all areas of practice. Leaders recognised the shortfalls identified and were taking action to address them, including strengthening care planning processes and improving how risks were identified, escalated, and monitored through audit and governance systems.
Mental Health Act training compliance was below expected levels for statutory training. This meant that a considerable proportion of staff had not completed required learning to support understanding of legal frameworks, detention processes, and patient rights. This increased the risk of inconsistent application of the Mental Health Act in practice. While governance and improvement processes were in place to monitor and address this, they had not yet fully translated into consistently high completion rates.
Despite this, the service had clear governance structures, defined roles and responsibilities, and established systems of accountability to support the delivery of safe and effective care. Staff and leaders demonstrated a general understanding of their responsibilities within these arrangements, and there was oversight of risk, performance and quality at ward and service level.
There was a clear framework for governance discussions, including learning from incidents, complaints, and safeguarding concerns. Staff understood how to escalate issues appropriately, and there were processes in place for sharing learning across teams.
Staff participated in local audits and quality monitoring activity, which supported identification of areas for improvement. Staff had system in place to escalate risks at ward level and understood how to escalate concerns when required.
Leaders demonstrated awareness of service risks and were responsive to issues raised through governance systems. Systems were in place for business continuity and emergency planning, and information governance arrangements supported secure handling of patient records.
 

We scored the service as 3. The evidence showed a good standard. The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.
The service demonstrated effective partnership working with external stakeholders to support joined-up care and service improvement. Directorate leaders engaged with key partners, including commissioners and Care Quality Commission to support oversight, feedback, and service development.
Staff and leaders understood their responsibility to work collaboratively with other organisations to ensure care was coordinated and responsive to people’s needs. This included sharing relevant information appropriately and working with partner agencies to support continuity of care and improve outcomes for patients.
We saw evidence of openness and transparency in how the service engaged with external stakeholders. Leaders and staff contributed to discussions with partners and were receptive to feedback, using it to inform ongoing improvements within the service.
Patients and staff had opportunities to engage with senior leaders and, where appropriate, commissioners to provide feedback about their experiences. This supported a two-way communication approach between the service and external stakeholders.
 

We scored the service as 2. The evidence showed some shortfalls. The service did not always focus on continuous learning, innovation and improvement across the organisation and local system. While there was a culture of learning and improvement, this did not consistently lead to timely improvements in practice.
While there was evidence of quality improvement activity through audits, incident learning, and feedback processes it did not always translate into consistent improvements across all areas of the service. We identified gaps in patient privacy protections, personalisation of care planning, and Mental Health Act training compliance.
However, staff were encouraged to reflect on practice, share ideas, and contribute to service development. Staff described having opportunities to raise suggestions for improvement and participate in discussions about how services could be delivered more effectively. This contributed to a culture where learning from experience was valued and used to support ongoing development. Where findings were identified, these were shared with teams and used to support reflection and improvement in practice.