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 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.

Staff and leaders demonstrated a proactive and systematic approach to learning from incidents. Lessons learned were clearly identified, shared across teams, and used to drive improvements in practice. Incidents, including episodes of agitation, aggression and falls, were managed promptly, with thorough and accurate reporting.

Post-incident debriefs were routinely undertaken with both patients and staff. Additional psychological support was available through the psychology team, including individual interventions and group reflective sessions, to promote learning and wellbeing.

Managers and clinical leads ensured that staff received regular and constructive feedback following incidents and investigations. Learning was embedded into everyday practice through structured handovers, team meetings and operational reviews, fostering a culture of continuous improvement. Staff engaged positively with feedback and were able to demonstrate how learning had been applied to enhance care delivery.

The trust conducted quarterly mortality review panels and had clear criteria aligned with the ‘Learning from Deaths’ framework for undertaking structured judgement reviews following patient deaths. These reviews provided a comprehensive assessment of the care delivered. Systems were in place to ensure that learning from both internal and external incidents was effectively shared across services. Staff and leaders reported that minutes from mortality review panels were routinely reviewed to identify recurring themes in patient safety incidents. Previously identified themes included the importance of clear documentation and maintaining competencies in immediate and basic life support.

Staff demonstrated a strong understanding of the duty of candour, ensuring open and transparent communication with patients and their families. This included providing clear explanations and offering apologies where appropriate.

Patients were supported and reassured throughout referral, admission, transfer and discharge processes, helping to reduce anxiety during periods of transition. They were provided with clear information about their care and treatment in a variety of formats to meet individual needs and preferences.

The service had effective systems in place to clinically review patients on waiting lists. Staff were able to access up-to-date information to monitor individuals and identify any changes in their presentation. A shared tracking system, including spreadsheets that enabled staff to record and review contact activity, ensuring oversight and continuity.

Patient referrals were discussed within multidisciplinary team (MDT) meetings, where structured and collaborative discussions supported safe and appropriate admissions. A consistent and structured admissions process was followed, including the timely completion of care plans and risk assessments.

Staff and leaders described arrangements to support safe admissions and effective discharge planning. Referral documentation, including clinical histories, risk assessments and care plans were reviewed thoroughly to ensure that patients received care appropriate to their needs. Leaders highlighted the importance of early planning and clear communication between teams.

MDT meetings, team handovers and staff meetings were used effectively to share information, supporting continuity of care and a coordinated approach to managing patients’ wellbeing in the community. Staff demonstrated a collaborative and professional approach in delivering care.

Discharge planning was well coordinated, with strong joint working across services to facilitate safe and timely transitions. Where delays occurred, these were clearly justified to ensure appropriate care and support arrangements were in place. Staff made ongoing efforts to minimise delays and remained focused on achieving timely discharges.

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.

Leaders ensured all safeguarding cases raised were tracked and an outcome recorded. There was a trust-wide dashboard for managers to monitor the number of safeguarding concerns raised, referrals made and if they were waiting for a local authority decision. Managers attended a fortnightly governance meeting where safeguarding referrals were discussed.

A review of serious incidents reported across all community mental health teams (CMHTs) during the periods of March 2026 and May 2026 and identified two incidents. Stamford CMHT reported one unexpected death, for which a patient safety review (PSR) was completed and no further actions were identified. Sleaford CMHT reported one serious incident involving a patient residing in a care home. A PSR was also completed for this incident, with no further actions required. No serious incidentswere recorded within any other CMHTs during the reporting period.

Carers of patients said that their loved ones and they themselves felt safe and empowered to raise concerns, knowing staff would support them appropriately, if they felt unsafe or had any concerns about others. One family member told us, “I do feel very safe because I know who to call when I need. The nurses will visit if I need them to and will not leave until we all feel safe in the house.”

Safeguarding incidents and concerns were routinely reviewed and discussed within multidisciplinary team 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.

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.

Risk assessments and crisis management/safety plans were current, reviewed and in relevant to individual care needs. The people who used services had well written and accurate risk assessments and crisis management plans in place.

We reviewed 9 risk management plans across the 4 locations that we visited. Risk assessments were person-centred and completed in line with trust policy. They reflected patients’ individual needs, preferences and identified risks, and were regularly reviewed to ensure they remained up to date. The service applied a balanced and proportionate approach to risk management, with observations and wellbeing checks adjusted appropriately in response to changes in patients’ presentation and level of need.

Staff managed patients’ needs, emotional responses and distress in a compassionate and therapeutic manner. They demonstrated an understanding of the underlying factors influencing behaviour and responded in ways that upheld 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 involvement in multidisciplinary team (MDT) reviews, supporting a collaborative and inclusive approach to care planning. Staff supported patients to understand their individual risks and how to manage them, adapting communication methods to meet a range of needs, including those with language barriers or communication difficulties.

Staff worked proactively with patients to increase their understanding of risks and triggers. This supported timely and appropriate interventions, helping to minimise distress and reduce risk within the community.

One family member of a patient told us, “At times it is unpredictable living with a person who has dementia, but the team know us well and know exactly what the concerns are when they see him or visit the house. The staff have helped me to understand what I can do to help and who I should contact if I ever needed additional support”.

Staff maintained clean, well-equipped environments that supported the physical and mental wellbeing of patients, staff and visitors. This included staff workspaces, public waiting areas and patient consultation rooms, all of which were observed to be orderly and appropriately maintained.

Staff undertook regular environmental safety audits. These ensured that potential hazards were promptly identified, accurately documented and appropriately mitigated. Ligature risks had been carefully assessed, with comprehensive risk management plans in place to effectively reduce and manage identified risks.

Staff assessed risks associated with individual patient visits and took appropriate action to maintain safety. Where required, additional staff were allocated to support patient appointments. All staff carried personal alarms, and CCTV systems were in place across the locations visited, providing additional oversight and reassurance.

Clinic rooms were clean, well organised and fit for purpose. Systems were in place to ensure regular checks of equipment and facilities, providing assurance that items were safe, functional and ready for use, including in emergency situations.

Facilities, equipment and technology were well maintained and supported the delivery of safe and effective care. Clear processes were in place to monitor cleanliness, safety and overall maintenance of the premises. Equipment was appropriate for its intended use, stored securely and used in line with relevant guidance.

Leaders and staff demonstrated a proactive approach to environmental safety, considering both physical and psychological risks. This included attention to reducing the risk of psychological harm, with consideration given to sexual safety and the diverse sensory needs of patients. These measures contributed to a safe and therapeutic care environment.

People who were carers for patients using the community mental health service reported that staff were accessible, responsive, and provided consistent support. One person told us, “I cannot say a single thing bad for the team. They provide us with the support that we need but also allow us to remain a family. I can keep my husband at home without worrying that he needs to be in a hospital or care home.”

Care records demonstrated that people were offered regular, planned one-to-one contact with their named care coordinator, including community psychiatric nurses and occupational therapists. This supported the development of therapeutic relationships, promoted continuity of care, and enabled ongoing assessment of individuals’ needs within the community. Protected clinical time with named professionals supported engagement in treatment and allowed staff to monitor progress and respond effectively to any deterioration or change in presentation.

Staff maintained regular contact with patients through a combination of face-to-face appointments, home visits, and remote consultations, ensuring a consistent and supportive presence. Staffing arrangements enabled timely access to multidisciplinary input, including psychiatrists, nurses, occupational therapists, psychologists, and pharmacists. Medical cover was available during core hours, with clear arrangements for out-of-hours support and urgent or emergency responses, providing reassurance to both patients using the service and staff.

Across the teams we reviewed, staffing levels were planned in line with the service establishment and caseload requirements. Caseloads were regularly reviewed to ensure they remained safe and manageable. Staffing gaps were addressed using regular bank staff where required, with no use of agency staff, which supported continuity of care and reduced disruption for patients using the service.

Team rotas and clinic schedules were planned in advance, with oversight from operational managers to ensure effective workforce deployment. Regular workforce and caseload review meetings were held to support safe staffing and proactive planning. Leaders demonstrated good oversight of staffing levels, skill mix, and caseload complexity.

Recruitment processes were robust and aligned with NHS safer recruitment standards. Pre-employment checks were consistently completed for all staff, including temporary workers, to ensure they were suitably qualified, experienced, and appropriate for their roles.

Staff described feeling well supported within their roles and reported having access to regular clinical and managerial supervision, reflective practice opportunities, and annual appraisals. At the time of the assessment, supervision compliance rates across the teams were 92% for clinical supervision and 87% for management supervision, while appraisal compliance was 95%. Staff did not raise any concerns regarding the quality, frequency, or accessibility of supervision, nor were any concerns expressed in relation to the appraisal process.

Mandatory and role-specific training was largely up to date, with overall compliance rates remaining high across the service ranging from 80% to 90% across whole teams. Training programmes were appropriate to the needs of the community mental health population and included risk assessment, safeguarding, medicines management, and crisis intervention. Staff demonstrated the skills, knowledge, and confidence to deliver safe, effective, and person-centred care. The trust recognised that performance in some areas was below the expected standard. Where non-compliance was identified, the director of operations provided assurance that all affected staff had been booked onto the next available training sessions.

Patients and the public using the community mental health service expressed confidence in the infection prevention and control (IPC) arrangements in place. Staff took appropriate precautions during visits and appointments to minimise the risk of infection. One person said, “Staff are always mindful about cleanliness and hygiene when they visit. It makes me feel safe.”

We observed that staff followed effective infection prevention and control practices when delivering care in a range of community settings, including clinics, patients’ homes, and local hubs. Staff adhered to hand hygiene protocols and used personal protective equipment (PPE) in line with current guidance where appropriate. Equipment used during visits was cleaned and maintained in accordance with service procedures.

Community clinic environments and team bases were clean, tidy, and well maintained. Cleaning schedules were in place, regularly reviewed, and evidenced that routine cleaning was carried out to maintain a safe and hygienic environment. Hand sanitising facilities were available within clinical areas, supporting staff, patients using the service, and visitors to reduce the risk of infection transmission.

Staff demonstrated a clear understanding of their responsibilities in relation to infection prevention and control. This included maintaining good hand hygiene, following safe working practices when visiting patients at home, and undertaking appropriate risk assessments where there were known or suspected infection risks.

The service had clear processes for the identification, assessment, and management of infection risks within the community. IPC policies reflected current national guidance and were embedded into everyday practice. Staff were able to describe the actions they would take in response to infectious risks, including escalation procedures and liaison with other services where required.

Regular IPC audits and environmental checks were undertaken across community bases to monitor compliance. Any identified issues were addressed, with clear action plans to support improvement where needed.

Information about infection risks was communicated effectively to staff and patients using the service. Staff provided advice to individuals and carers, where appropriate, to support safe care delivery within the home environment. There were clearly defined roles and responsibilities for IPC, supported by ongoing training to ensure staff knowledge remained current and aligned with best practice standards.

Patients using services were supported, wherever possible, to be involved in decisions about their medicines. For individuals with capacity, staff ensured they understood the purpose, benefits, and potential side effects of their medication, and actively involved them in decisions about starting, stopping, or changing treatment. Where patients were unable to fully understand or participate, for example, due to cognitive impairment or acute mental health needs, staff followed best-interest decision-making processes in line with the Mental Capacity Act 2005 and, where applicable, the Mental Health Act. Care records clearly reflected each person’s level of understanding and documented their involvement in medicines management.

Staff adhered to safe and effective practices across all aspects of medicines optimisation within the community setting. This included prescribing, administration, monitoring, reconciliation, and documentation. Staff worked in line with national guidance and professional standards, and we saw evidence that discussions about medicines formed a routine part of clinical reviews and care planning.

Medicines were managed safely across community clinics, team bases, and during home visits. Where medicines were stored on site, including controlled drugs, these were held securely in line with legal and organisational requirements. Required checks, such as fridge temperature monitoring and stock control, were completed and recorded appropriately. Staff ensured that medicines were transported safely when required and that any unused or expired medicines were disposed of in accordance with local procedures.

Staff supported patients to manage their medicines safely within their own homes, including providing advice, monitoring adherence, and working collaboratively with GPs and pharmacists. Medicines reconciliation was completed promptly when patients transitioned between services, including discharge from inpatient care, to ensure continuity of treatment and reduce the risk of error.

A review of medicines-related incidents across all teams for the period March 2026 to May 2026 identified a low number of reported incidents. Within Stamford and Grantham OA CMHT, one prescribing incident was reported. This was categorised as a no-harm/near-miss event, and no formal investigation was required. Within Louth OA CMHT, one prescribing-related incident was reported involving a GP practice and was not attributable to LPFT. This incident was also categorised as a no-harm/near-miss event, and no formal investigation was required. No medication errors or medicines-related incidents were reported within any of the other OA CMHTs during the reporting period. Medicines incidents continued to be recorded, monitored, and reviewed through established governance processes to support learning and maintain patient safety.

The service maintained effective systems and governance processes for medicines optimisation. Prescribing practice was in line with national guidance, and there was appropriate oversight of high-risk medicines and controlled drugs. Regular medicines audits were undertaken, with findings used to improve practice.

Staff received appropriate training and competency assessments relevant to their roles, including medicines management, safe prescribing, and administration where applicable. Staff demonstrated confidence and competence in supporting patients with their medicines and understood their responsibilities in promoting safe and effective use.