Lincolnshire Partnership NHS Foundation Trust

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe - this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question Good. At this assessment the rating has remained Good. This meant people were safe and protected from avoidable harm.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Description: We have a proactive and positive culture of safety based on openness and honesty, in which concerns about safety are listened to, safety events are investigated and reported thoroughly, and lessons are learned to continually identify and embed good practices.

Staff and leaders demonstrated a proactive approach to learning from incidents, ensuring lessons were identified, shared across teams, and used to improve practice. Incidents such as agitation, aggression, and falls were responded to promptly, with accurate reporting and timely updates to care plans and risk assessments to reflect learning.

Post-incident debriefs were routinely carried out with both patients and staff, with additional support provided by the psychology team through individual and group reflective sessions.

Managers and clinical leads ensured staff received regular feedback following incidents and investigations. Learning was embedded into daily practice through handovers, team meetings, and operational reviews, supporting continuous improvement. Staff engaged positively with feedback and demonstrated how learning was applied to enhance care delivery.

Staff showed a strong understanding of the duty of candour, maintaining open and honest communication with patients and families, including providing explanations and apologies when appropriate.

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

Patients were well supported and reassured throughout referral, admission, transfer, and discharge processes, which helped to minimise anxiety during periods of transition. They had access to information about what to expect from their care and treatment, provided in a range of formats to meet individual needs and preferences.

Leaders held admission meetings and structured handovers to prepare staff for each new patient, supporting safe and smooth transitions into the service. A structured admissions process was followed, including completion of a checklist on the day of admission, reviewed at 72 hours, and prompt follow-up of any missing information to ensure safe and effective care planning.

Staff and leaders described robust systems in place to ensure safe admissions and effective discharge planning. Referral documentation, including clinical history, risk assessments and care plans, was reviewed thoroughly to ensure the service could safely meet each patient’s needs. Leaders emphasised the importance of early planning and clear communication across teams.

We observed several meetings, including multidisciplinary team (MDT) meetings, staff meetings and handovers. During these, staff shared information effectively to support continuity of care and demonstrated a collaborative and professional approach to managing patients’ transitions.

Discharge planning was well coordinated, with close working between services to support safe and timely transitions. Where delays occurred, these were clearly justified and related to ensuring appropriate care and support arrangements were in place. Staff made consistent efforts to minimise delays and remained focused on achieving timely discharges.

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

Staff demonstrated a consistent understanding of safeguarding principles and were able to recognise a wide range of potential concerns, including signs of abuse, neglect, exploitation and discrimination. They responded appropriately and without delay, taking action to protect patients and ensure their safety and wellbeing. Staff were clear about their individual responsibilities and followed established safeguarding procedures, including escalating concerns and making referrals to external safeguarding authorities when required. They worked collaboratively with partner agencies to ensure a coordinated and effective response.

Patients felt safe and empowered to raise concerns, knowing staff would support them appropriately, if they felt unsafe or had any concerns about others. One patient told us, “I do feel very safe. Sometimes it can get a bit noisy, but staff are always there and they help you to stay safe.”

Safeguarding incidents and concerns were routinely reviewed and discussed within multidisciplinary team [CW1]meetings (MDT) and staff forums. This supported a culture of openness, reflection and shared learning, enabling teams to identify trends, improve practice and strengthen preventative measures.

Staff demonstrated a clear understanding of the Deprivation of Liberty Safeguards (DoLS) and applied them appropriately, ensuring that any restrictions placed on patients were lawful, proportionate and in the patient’s best interests. They showed awareness of the importance of least restrictive practice and regularly considered patients’ rights when making care and treatment decisions.

Leaders played an active role in ensuring staff were well supported, trained and confident in managing safeguarding concerns. They promoted a culture where safeguarding was seen as everyone’s responsibility and where staff felt empowered to raise concerns without hesitation. Ongoing training, supervision and reflective discussions reinforced good practice and ensured safeguarding remained a key priority within the service.

We reviewed internal allegation records and electronic incident reporting[CW2] data for both Langworth and Brant wards for January to March 2026, including any outstanding concerns from December 2025. No safeguarding allegations of this nature were identified during this period.

Across both wards, incident reviews showed a small number of reports relating to sexual safety; these were linked to privacy and dignity concerns associated with sexual disinhibition and were appropriately managed by ward staff, with no harm identified. Incidents relating to self-neglect and patient-on-patient violence, abuse, or harassment were recorded at no or low harm levels and did not meet the threshold for a safeguarding referral. These were appropriately managed within the wards in line with local processes.

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

We reviewed 8 risk management plans across both wards. Risk assessments were person-centred and reviewed in line with trust policy, reflecting patients’ individual needs, preferences and identified risks. The service adopted a balanced and proportionate approach to risk management, with levels of observation and wellbeing checks adjusted appropriately in response to patients’ changing presentations and levels of need.

Staff managed patients’ needs, emotional responses and distress in a compassionate and therapeutic manner. They demonstrated an understanding of the underlying causes of behaviour and sought to respond in ways that preserved patients’ dignity, rights and autonomy.

Patients, and where appropriate their relatives, were actively involved in risk assessment and management processes. There was clear evidence of their participation in multidisciplinary team reviews, supporting a collaborative and inclusive approach to care planning. Staff also supported patients to understand their own risks and how to manage them, adapting communication methods to meet individual needs, including for those with language barriers or communication difficulties.

Staff supported patients to understand their individual risks, which ensured they intervened and responded quickly to support patients to minimise any distress and to decrease risk. One patient told us, “I am at risk of falls, the staff have helped me to understand what this means and got me my walker. Staff are always there keeping an eye on me to make sure I’m okay.”

Restrictive interventions, including restraint, were used only as a last resort and in line with best practice guidance. Care plans clearly documented any restrictions and the rationale for their use. Staff demonstrated awareness of equality and human rights legislation when considering and implementing restrictions, ensuring decisions were lawful, proportionate and in the patient’s best interests. Where rapid tranquillisation was required, it was administered and documented appropriately, in line with national guidance, with clear records demonstrating clinical rationale and post-incident monitoring.

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

Patients and staff felt the environment was safe. One patient told us, “The staff are always around, and there are buttons all over the place which you can press if you ever need help.”

Staff effectively maintained clean, and well-equipped environments that promoted the physical, and mental wellbeing of the patient and supported the safe delivery of care. Equipment was stored safely and used appropriately for its intended purpose.

We observed that staff completed regular safety audits of the care environment. This ensured that potential hazards were promptly identified, clearly documented, and appropriately mitigated. Attention was given to ligature risks; these had been thoroughly assessed, with comprehensive risk management plans in place to minimise and manage any identified risks effectively.

Staff were equipped with personal alarms, enabling them to summon assistance quickly if required. In addition, patients had access to nurse call systems, ensuring they were able to request support promptly and safely when needed.

Clinic rooms were observed to be clean, well-organised, and suitably maintained. They were fully equipped with accessible resuscitation equipment and emergency medicines. Systems were in place to ensure these were checked regularly by staff, providing assurance that equipment was functional and ready for use in the event of an emergency.

Facilities, equipment, and technology were well maintained and consistently supported staff in delivering safe, effective care. Staff had clear and effective processes in place to monitor the safety, cleanliness, and overall upkeep of the premises. Equipment used in the delivery of care and treatment was appropriate for its intended purpose, stored securely, and used in line with guidance.

Leaders and staff demonstrated a proactive approach to safety by considering both physical and psychological risks within the care environment. This included thoughtful consideration of how the environment could reduce the risk of psychological harm, with particular attention given to sexual safety and the diverse sensory needs of patients. These considerations contributed to a safer, more therapeutic environment for people using the service.

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

Patients were well supported, staff were always present, visible, and available. One patient told us, “I’ve been to a few different hospitals, and the staff here are great. The staff are always around, and there always seems to be plenty of them.” Patients were supported to have regular one-to-one time with their named nurse which we found evidence of in the care records we reviewed. This maintained therapeutic relationships and promoted continuity of care.

Patients also had regular, protected one-to-one time with their named nurse and occupational therapist. This supported continuity of care promoted engagement in treatment, and enabled staff to monitor progress and respond to changing needs effectively.

We observed that staff maintained a constant presence in communal areas, which contributed to a safe and supportive environment. Staffing arrangements ensured there was sufficient medical cover throughout both day and night shifts. Doctors and pharmacists were available and able to respond promptly to any urgent or emergency situations, providing reassurance to both patients and staff.

On Langworth ward, staffing levels were maintained in line with the planned establishment of three qualified nurses and four healthcare assistants during the day (with four qualified nurses and three healthcare assistants on Mondays and Wednesdays), and two qualified nurses with three healthcare assistants at night. All shifts over the four-week period were fully covered through the use of bank and agency staff.

On Brant ward, staffing levels were also maintained in line with the planned establishment of three qualified nurses and three healthcare assistants during the day, and two qualified nurses with two healthcare assistants at night. All shifts were covered during the same period, supported by bank staff only, with no use of agency staff.

Across both wards, rotas were planned and issued three months in advance, with monthly rota hygiene meetings facilitated by the scheduling team to support effective workforce planning.

Leaders demonstrated effective oversight of staffing levels and skill mix. They routinely reviewed staffing in line with patient acuity and dependency levels and adjusted where necessary. We saw evidence that staffing levels were flexed in response to changes in patient need, ensuring that care and support remained safe, responsive, and person-centred at all times.

Recruitment processes were robust and aligned with safe recruitment practices, ensuring all staff, including temporary workers, were suitably qualified, experienced, and appropriate for their roles. Pre-employment checks were consistently completed, with clear systems in place to verify staff suitability.

Staff reported feeling well supported, with access to regular supervision and annual appraisals. Mandatory training was up to date and relevant to the patient group, supporting staff to deliver safe care with confidence.

A positive learning culture was promoted, with opportunities for professional development and career progression. Performance concerns were addressed promptly and managed in a fair, consistent, and supportive manner.

Staff reported feeling supported by the leadership team and stated that they received regular clinical and managerial supervision each month. Staff also completed annual appraisals and personal development reviews. Data reviewed up to the end of March 2026 showed strong compliance across both wards. Within Brant ward clinical supervision was at 100%, managerial supervision at 92%, and staff appraisals at 100%. Langworth clinical supervision was at 92%, managerial supervision at 72%, and staff appraisals at 73%.

Mandatory and role‑specific training was also completed and maintained by staff, with an overall compliance rate of 87% within Langworth and Brant being 93% at the time of our assessment. The training available was appropriate for the needs of the patient group, and staff demonstrated confidence and competence in delivering safe, effective and person‑centred care.

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

Patients were confident in the infection prevention and control (IPC) processes in place and felt assured that staff were taking necessary precautions to protect them from the risk of infection and potential harm. One patient told us, “The cleaners are always about keeping the place nice and clean. They’re lovely and always make time to have a chat with you.” Throughout our visit, we observed all areas to be clean, tidy and well maintained.

Staff consistently adhered to effective infection prevention and control practices. We observed that staff followed hand hygiene protocols appropriately, used personal protective equipment (PPE) in line with guidance, and ensured that equipment was cleaned thoroughly in accordance with the service’s procedures.

All ward areas were clean, tidy, and well maintained. Cleaning schedules were comprehensive, up to date, and evidenced that regular cleaning was carried out to maintain a safe and hygienic environment. During our observations, staff demonstrated a clear understanding of their roles in relation to infection control and consistently followed good practice, including appropriate handwashing techniques. Hand sanitising stations were readily available throughout the ward, supporting staff, patients, and visitors to minimise the risk of infection transmission.

The service had clear and robust processes in place for the identification, assessment, and management of infection risks. Infection prevention and control policies reflected current national guidance and were embedded in practice. Regular cleaning and IPC audits were completed to monitor compliance, and any identified issues were addressed promptly and effectively.

Information relating to infection risks was communicated appropriately to staff, patients, visitors, and relevant external agencies, ensuring a coordinated and safe approach. There were clearly defined roles and responsibilities for infection prevention and control, supported by ongoing staff training to ensure practice remained up to date and aligned with best practice standards.

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

Patients were supported, where possible, to be involved in decisions regarding their medicines. For individuals with capacity, staff ensured they understood the purpose of their medication and actively included them in any decisions or changes to their treatment. Where patients were unable to fully understand or participate, for example due to dementia or other cognitive impairments, staff followed best-interest decision-making processes in accordance with the Mental Capacity Act 2005 and the Mental Health Act. Care plans clearly reflected each individual’s level of understanding and documented the extent of their involvement in managing their medicines.

Staff adhered to safe and effective practices across all aspects of medicines management, including the transport, storage, dispensing, administration, reconciliation, recording, and disposal of medicines. They worked in line with national guidance and professional standards and demonstrated how patients were involved in discussions about their treatment wherever possible. When covert administration of medication was necessary, appropriate legal frameworks were followed, including capacity assessments, best-interest meetings, and regular reviews.

We observed staff administering medicines safely and respectfully, providing clear explanations to patients where appropriate. Medicines, including controlled drugs, were stored securely and managed in accordance with legal requirements. Daily checks of fridge and room temperatures were completed, and all medicines were within their expiry dates. Expired or unused medicines were disposed of safely. Staff ensured that medicines were not used inappropriately to control behaviour.

On Langworth ward, there were 10 medication-related incidents reported between January and March 2026, 7 administering and 3 multifactorial. On Brant ward, there were 12 incidents reported during the same period, eight administering, two related to discharge summaries, one multifactorial, and one prescribing. All incidents across both wards were recorded as no harm or near misses, and none required formal investigation, indicating that risks were identified and managed effectively.

The service maintained robust systems for medicines management that reflected current best practice. Prescribing followed national guidance, and continuity of care during transitions between services was supported through effective medicines reconciliation and accurate documentation. Controlled drugs were subject to the appropriate governance and oversight. Regular audits were completed, with findings acted upon. A culture of learning was promoted through incident reporting and review. Staff received appropriate training and competency assessments to support the safe, effective, and appropriate use of medicines.