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 this key question requires improvement. At this assessment, the rating has remained Good. This meant people’s outcomes were consistently good, and people’s feedback confirmed this.

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.

Family members of patients told us that staff took the time to listen to them and understand their individual needs. They were supported, wherever possible, to be involved in their assessment and care planning. Staff made efforts to engage patients in discussions about their needs, preferences, and recovery goals. However, we recognised that some individuals were not always able to fully participate due to the nature or severity of their mental health conditions. In these situations, staff adapted their approach, used appropriate communication methods, and offered additional support to maximise involvement.

Where patients lacked the capacity to fully engage in decisions about their care, staff followed relevant legal frameworks and best-interest decision-making processes in line with the Mental Capacity Act 2005. Decisions were made in a way that respected patients’ rights, dignity, and previously expressed wishes wherever these were known. When individuals were unable to communicate their views directly, staff sought input from family members, carers, and advocates to ensure that assessments and care planning remained person-centred and reflective of the individual’s values and preferences.

Staff completed timely, comprehensive, and holistic assessments of patient’s mental health, physical health, emotional wellbeing, social circumstances, and communication needs. Assessments were recovery-focused and informed by both recognised clinical tools and professional judgement. These were reviewed regularly, and updated in response to changes in need, risk, or circumstance, ensuring they remained relevant and responsive.

Assessments were carried out across a range of community settings, including clinics, patients’ homes, and through remote appointments, ensuring flexibility and accessibility. Staff demonstrated a structured and consistent approach to assessment, which informed care planning and risk management.

For individuals with reduced capacity, staff ensured that decisions were made lawfully and in their best interests, with clear and comprehensive documentation to support this. Carers and family members were involved in assessments where appropriate and were supported through clear communication and access to relevant information.

We reviewed a sample of care records during the assessment. These showed that initial assessments were completed in a timely manner following referral or transfer into the service, including comprehensive mental health and physical health assessments. Care plans were developed based on identified needs and were holistic and outcome focused.

Records demonstrated that care plans and risk assessments were reviewed regularly and updated as required. Communication needs were clearly documented, and reasonable adjustments—such as the use of accessible language, visual prompts, or adapted communication approaches—were used to support patients understanding and engagement.

Staff delivered care and treatment in line with evidence-based guidance, including recommendations from the National Institute for Health and Care Excellence (NICE). They had access to regular clinical updates and demonstrated knowledge of current best practice relevant to community mental health care. Care we reviewed across community settings was consistent with national guidance and reflected a recovery-focused approach.

Physical health and wellbeing were appropriately considered as part of holistic care. Where patients had specific dietary needs or risks, these were identified through assessment and addressed within care planning. Staff considered clinical needs, cultural preferences, and personal choice, and worked collaboratively with GPs and other services where required to ensure appropriate nutritional support. Needs were reviewed regularly and adjusted in response to changes in health or risk.

Occupational therapy (OT) provision within the community pathway was well coordinated, person centred, and fully integrated within the multidisciplinary team (MDT). Staff described a positive and collaborative team environment, which supported the delivery of meaningful, recovery-focused interventions in community settings, including patients homes and clinics. One-to-one interventions and group-based activities were used, where appropriate, to enhance engagement and promote independence.

OT practice was structured, consistent, and informed by recognised frameworks, including the Model of Human Occupation (MOHO). Assessments and interventions focused on supporting individuals to engage in meaningful activities, improve daily functioning, and achieve personal recovery goals. All therapeutic activity was recorded on the electronic patient record system, supporting clear communication, continuity of care, and effective service oversight.

There were clear and effective risk management processes in place. Staff demonstrated how risks were identified, documented, and managed collaboratively within the MDT. This included appropriate escalation processes, liaison between professionals, and regular review of risk within team meetings. This approach ensured shared accountability for safety and supported timely responses to changes in presentation or risk.

Patients using the service were actively involved in care planning, goal setting, and treatment reviews wherever possible. Interventions were adapted to reflect individual capacity, needs, and legal status, ensuring care remained inclusive, safe, and focused on meaningful participation. Staff demonstrated a clear commitment to delivering evidence-based, person-centred care that supported recovery and improved outcomes within the community.

Patients received coordinated and integrated care across teams and partner agencies. Staff worked collaboratively within multidisciplinary teams (MDTs), which included psychiatrists, community psychiatric nurses, psychologists, occupational therapists, social workers, support workers, and external partners. Relevant professionals were routinely involved in reviews of care, helping to ensure continuity and a joined-up approach for individuals and their carers. A family member told us, “Everyone involved in my mum’s care works well together. They’re always contact me or my mum to check on her between appointments. If I need anything outside of what the nurses can provide, they will sign post me or help with referrals.”

Staff described positive and effective working relationships both within their immediate teams and across the wider health and social care system. Regular multidisciplinary team meetings were held to review patients care, treatment, and risk. These meetings ensured that care plans were discussed, updated, and responsive to changes in need. Staff also reported effective collaboration with other services, including primary care, crisis teams, inpatient services, and voluntary sector organisations.

We observed that team meetings and case discussions were structured, focused, and centred on delivering safe, person-centred and recovery-oriented care. Information sharing within teams was effective, supported using electronic patient record systems, which enabled timely communication and continuity of care.

Clear systems and processes were in place to support coordination when patients moved between services or required input from multiple providers. Transitions, including discharge from inpatient services or step-up to more intensive support, were planned in a timely and person-centred way. Staff worked proactively to ensure that referrals, information sharing, and follow-up arrangements were completed promptly, reducing the risk of gaps in care.

Care coordination was a key strength within the service. Named care coordinators-maintained oversight of individuals’ care, ensuring that interventions were well organised and delivered in line with assessed needs and recovery goals. Staff engaged effectively with carers and families, where appropriate, to support holistic care and shared decision-making.

Staff supported patients to manage their physical health and overall wellbeing, promoting independence and encouraging healthier lifestyle choices as part of a holistic, recovery-focused approach. Patients using the service were offered access to health promotion interventions, including smoking cessation advice, healthy eating support, and opportunities to increase physical activity, such as walking groups and community-based activities.

Staff worked collaboratively with individuals to identify achievable health goals and encouraged participation in meaningful activities that supported both mental and physical wellbeing. This included signposting and referral to local community resources and structured programmes, such as gardening or horticultural projects, which provided opportunities for social inclusion, skill development, and increased physical activity.

Where patients required additional support with nutrition, staff provided guidance and worked alongside primary care and other services to promote healthy dietary choices. Individuals were encouraged to make informed decisions about their diet, considering personal preferences, cultural needs, and physical health conditions. A family member told us, “The nurses provide encouragement and advise on better ways of working to support my husband but also myself”.

Patients received regular physical health monitoring in line with national guidance, particularly where they were prescribed medication that required ongoing review or had long-term health conditions. Staff completed and recorded physical health checks and used this information to identify any emerging concerns at an early stage.

When specific health needs were identified, staff made timely referrals to appropriate specialist services, such as primary care, dietitians, or speech and language therapy, to ensure that individuals received the right support. This demonstrated a proactive and coordinated approach to meeting patients holistic health needs within the community.

Staff placed a strong emphasis on early identification and management of potential health risks. Through structured assessments, regular contact, and professional judgement, staff were able to recognise early signs of deterioration and take prompt action. This supported preventative care and reduced the risk of escalation or crisis.

Care was delivered in a way that promoted independence, self-management, and personal responsibility for health and wellbeing. Staff supported patients to retain as much independence as possible while ensuring appropriate support was in place to manage risk.

Staff consistently monitored patients’ care and treatment to support the delivery of safe, effective and outcome-focused care. They used a range of recognised clinical tools and outcome measures, including the Health of the Nation Outcome Scales (HoNOS) and routine physical health assessments, to establish baseline needs, assess level of risk and need, and monitor progress over time. This structured approach enabled staff to evaluate the effectiveness of interventions, identify emerging risks, and ensure care remained responsive to both clinical need and individuals’ recovery-oriented goals.

The service had effective systems in place to monitor, review and improve care and treatment outcomes. Staff were actively involved in this process and took accountability for adapting care in response to patients’ changing mental and physical health needs. Digital systems were used appropriately to support accurate documentation, information sharing and multidisciplinary communication.

Care plans were reviewed regularly and updated to reflect current needs, preferences and identified risks, ensuring they remained person-centred, recovery-focused and in line with best practice. Staff also engaged in clinical audit and benchmarking activity to assess performance, identify areas for improvement, and enhance service delivery. Learning from audits and outcome measures was used to inform service development, improve care pathways and support continuous quality improvement.

The Lincoln community dementia service pilot and community diagnostic centre (CDC) and memory assessment clinic resulted in improved access to assessment and diagnosis for patients with dementia. Between August 2025 and February 2026, open dementia referrals reduced from 807 to 508, and the number of patients waiting for assessment reduced from 416 to 291. The redesigned pathway enabled patients to receive diagnostic tests, assessment, and treatment planning in a more streamlined manner, reducing the time between assessment and diagnosis. Clinic activity increased steadily throughout the pilot, demonstrating improved capacity and throughput. Feedback from patients, carers, and staff was overwhelmingly positive, with the service being recognised for providing a more efficient, patient-centred experience and reducing the burden associated with attending multiple appointments. The success of the pilot supported plans to expand the CDC model across Lincolnshire, including the development of clinics in Grantham, Skegness, and Boston.

Staff supported patients to make informed decisions about their care and treatment wherever possible, promoting independence, choice and autonomy. Information about care and treatment options was provided in a clear, accessible way, and staff took time to explain this to ensure patients could actively participate in decisions about their care.

Where patients’ capacity to make specific decisions was in question, staff completed and recorded decision-specific mental capacity assessments in line with the Mental Capacity Act 2005. These were undertaken for significant or complex decisions and demonstrated adherence to the five statutory principles of the Act, including supporting individuals to make their own decisions wherever possible. Where patients were assessed as lacking capacity, best interest decisions were made appropriately, with clear rationale documented. Staff considered the patient’s wishes, feelings, cultural background, values and previous experiences, ensuring a person-centred and least restrictive approach.

Family members of patients provided positive feedback about their involvement in care decisions. One person told us, “Staff explain any updates within my mum’s care, they will discuss her health and medication updates including possible side effects that we should all be aware of. Including what I should do to help if I see any signs.

Staff demonstrated a good understanding of relevant legal frameworks, including the Mental Health Act 1983, the Mental Capacity Act 2005 and the Equality Act 2010. For patients subject to the Mental Health Act, staff ensured that their rights were explained in a timely and appropriate manner. This included providing information about their legal status, rights of appeal, and access to advocacy services. Records showed that rights were reviewed regularly and re-explained when there were changes in legal status, responsible clinician, or care and treatment plans, in line with statutory requirements.

Consent to care and treatment was sought and recorded in accordance with legal and professional guidance. Where applicable, appropriate legal documentation was completed and maintained, and records were accurate and up to date. There were no concerns identified in relation to the use or recording of consent processes.