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, and fair culture. At our last assessment we rated this key question Good, at this assessment, the rating has remained Good.

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

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

The service demonstrated a 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.

Staff had opportunities to contribute to discussions about the service’s strategy, particularly during periods of change or development. This inclusive approach helped staff feel valued and engaged and reinforced a sense of shared ownership. Staff were able to clearly articulate how their roles contributed to delivering high-quality, person-centred care while working within available resources.

Both staff and leaders demonstrated a strong awareness of equality, diversity, and human rights, and applied these principles in practice. The service took steps to identify and address potential workforce inequalities and actively promoted an inclusive working environment. This approach supported the delivery of equitable care and positive outcomes for all patients using the service.

Leaders showed an understanding of risks to the delivery of the service’s strategy and had processes in place to identify, monitor, and respond to these risks. Action plans were developed and regularly reviewed, with progress communicated clearly to staff. appreciated being kept informed and involved, which contributed to a culture of openness and trust.

The provider’s strategy was focused on delivering safe, effective, and compassionate care, while also promoting staff engagement, equality, partnership working, and financial sustainability. Staff reported that clear communication, shared goals, and strong leadership supported them to perform their roles effectively and contributed to improved patient outcomes.

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

Leaders demonstrated the skills, knowledge, and experience to carry out their roles effectively. There was a clear management structure in place, with defined lines of accountability and responsibility, ensuring that leaders at all levels understood their remit and were well informed about key risks, priorities, and service developments. Leaders showed a comprehensive understanding of the services they managed and were able to clearly articulate how their teams delivered safe, effective, and high-quality care.

Leaders were visible and accessible within the service, maintaining a regular presence on the wards which fostered positive relationships with both staff and patients. Managers were described as approachable and supportive, this encouraged open communication and staff engagement. Leaders acted as inclusive role models, consistently demonstrating the organisation’s values in their behaviour and decision-making.

There was a strong focus on leadership development and progression. Staff were provided with opportunities to grow and develop within the organisation, supported by training, mentoring, and structured development pathways. We heard examples of staff progressing through different roles and bandings, including progression from entry-level positions to senior leadership roles, reflecting the organisation’s commitment to nurturing talent and retaining staff.

Leaders were also proactive in identifying and addressing cultural issues that could impact on the quality of care or staff wellbeing. They promoted a positive, inclusive working environment where concerns were raised and acted upon. This approach supported and enhanced staff morale, encouraged continuous improvement, and contributed to the delivery of safe, compassionate, and person-centred care.

Description: We create a positive culture where people feel that they can speak up and that their voice will be heard.

The service had a clear Freedom to Speak Up policy and procedure in place, which was well understood by staff. Staff had access to a designated Freedom to Speak Up Guardian and told us they felt safe, supported, and encouraged to raise concerns when necessary. Leaders actively promoted an open and transparent culture, where speaking up was valued and concerns were listened to, taken seriously, and acted upon in a timely manner.

Staff received training on whistleblowing processes and demonstrated a good understanding of how to raise concerns through the appropriate channels. They were confident in using these processes and reported that they would feel comfortable escalating issues without fear of reproach.

Leaders maintained oversight of Freedom to Speak Up concerns, regularly reviewing issues raised to identify any recurring themes or patterns. Concerns were analysed by factors such as staff group, role, or department, enabling leaders to gain a clear understanding of underlying issues. Action plans were developed in response to identified concerns, and progress was monitored to ensure improvements were implemented and sustained.

Staff felt confident that their concerns would be taken seriously and would lead to meaningful change. This approach supported a culture of openness, learning, and continuous improvement, contributing to both staff wellbeing and the delivery of safe, high-quality care.

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

Leaders demonstrated a strong commitment to equality, diversity, inclusion, and human rights. These principles were embedded in both the delivery of care and the way staff were supported and were reflected in everyday practice across the service. Leaders actively promoted these values, ensuring they remained central to the culture and guiding how the service delivered care.

Leaders took proactive steps to review and improve the organisational culture, with a clear focus on fairness, respect, and inclusion. Staff were treated with kindness, dignity, and respect, and there were systems in place to identify, monitor, and address any instances of inequality or variation in staff experience. Particular attention was given to the experiences of staff with protected characteristics or those from marginalised groups, helping to ensure that opportunities and support were equitable.

The service demonstrated a commitment to making reasonable adjustments for staff where required, including those with disabilities or additional needs. Flexible working arrangements were also available and actively supported, and enabled staff to balance their professional responsibilities with personal commitments. These measures contributed to a positive and inclusive working environment, supporting staff wellbeing, engagement, and retention.

Leaders actively promoted a culture of inclusion and took clear steps to prevent, identify, and address bullying and harassment within the service. They fostered an environment where all staff felt respected and supported, and where unacceptable behaviours were challenged appropriately and in a timely manner.

Leaders also worked to ensure that all staff voices were heard, including those who may be less visible or less likely to speak up. They encouraged engagement and participation across the workforce, creating opportunities for staff to contribute to the development and improvement of services.

Equality, diversity, and inclusion were clearly embedded within the organisation’s core values and strategic priorities. These principles were reflected in everyday practice and decision-making, supporting a fair, respectful, and inclusive working environment for all staff.

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

There were clear governance and management systems in place that supported the delivery of safe, high-quality, and sustainable care. Roles and responsibilities were well defined, and staff demonstrated a clear understanding of their duties and accountability within the team. Managers provided effective oversight and ensured staff were supported to meet the expected standards of care.

Regular team meetings were held and consistently covered key areas such as incidents, complaints, safeguarding, and service updates. Staff engaged with these processes and acted on learning from incidents, audits, and reviews. This reflected a culture of continuous improvement, where feedback and findings were used to strengthen practice and reduce risk.

Staff worked collaboratively both within the service and with external partners to ensure patients’ needs were met. There was a shared approach to managing risk, supported by an up-to-date and accessible risk register. Staff were aware of current risks and demonstrated confidence in escalating concerns appropriately. Emergency preparedness arrangements were in place, including plans for adverse weather conditions and outbreaks, ensuring the service could respond effectively to unforeseen events.

Information technology systems generally supported the delivery of care, enabling staff to document and share clinical information securely. However, there were ongoing issues with the reliability of the internet connection, which at times made it more difficult for staff to record care in a timely manner. Leaders were aware of this issue and had taken steps to address it, with work ongoing to improve system reliability.

Managers had access to timely and accurate performance data, which supported effective monitoring, governance, and decision-making. Leaders met their statutory responsibilities by submitting required notifications to external bodies, including the Care Quality Commission, in a timely manner.

The service implemented recognised quality improvement frameworks and encouraged innovation, supported by a proportionate and well-managed approach to risk.

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

Staff and leaders demonstrated a commitment to openness, transparency, and active engagement with external stakeholders. They worked collaboratively with commissioners, partner organisations, and other key agencies to support effective service delivery and promote integrated, person-centred care. These partnerships enabled a coordinated approach to meeting patients’ needs and ensured continuity across care pathways.

Leaders contributed to local and regional networks, sharing learning and best practice with partner organisations. This collaborative approach supported service development and continuous improvement, helping to strengthen the quality and consistency of the care they provided.

Managers actively sought feedback from local communities, partner agencies, and stakeholders. Leaders used this feedback to inform service planning, identify areas for improvement, and explore innovative approaches to care delivery. Engagement supported the development of services that were responsive to the needs of the population and aligned with wider system priorities.

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

Staff demonstrated a strong commitment to continuous learning and improvement. Leaders and staff understood how to implement and sustain change, consistently applying quality improvement approaches to enhance care delivery. For example, when an increase in patient falls was identified, staff responded promptly by reviewing observation levels, made referrals to physiotherapy, considered environmental adjustments such as relocating bedrooms closer to the nurse’s station, and discussed care needs at dedicated falls meetings.

Leaders encouraged a culture of openness, where staff felt confident to share ideas for improvement. Opportunities were created for collective reflection, learning, and problem-solving. Patients, along with their families and carers, were actively involved in shaping and evaluating service improvements.

The wards participated in relevant national audits and accreditation programmes, using findings to inform practice and drive improvements. Staff engaged in research activities, and evidence-based practice was embedded into care delivery.

Strong links with external partners further supported innovation and development. Leaders maintained open communication with staff, which fostered a culture of trust where ideas for change were encouraged, valued, and acted upon.