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. This key question has been rated 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.

We scored the service as 3. The evidence showed a good standard of care.

Staff demonstrated a proactive approach to promoting safety and embedding learning across the service. Incidents, near misses, and safeguarding concerns were reported consistently through the organisation’s electronic incident reporting system. Staff understood their responsibilities for reporting incidents and completed reports promptly when events occurred. This was reflected in the records we reviewed and appeared embedded within everyday practice.

Learning from incidents was routinely discussed within team meetings, handovers, and clinical governance forums to ensure lessons were shared and understood across the service. Staff were able to describe examples where learning from safeguarding concerns and incidents involving risk-taking behaviours in the community had resulted in changes to practice. This included strengthening collaborative working with partner agencies and other professionals to better manage risks and reduce the likelihood of similar incidents occurring in the future.

Staff felt able to raise concerns and were supported to do so within an open and transparent culture. Following incidents, staff had access to structured debriefs and reflective discussions to support their wellbeing and identify opportunities for learning and service improvement. People using the service were also offered opportunities to debrief and discuss incidents where appropriate.

Regular incident review and risk management meetings enabled teams to monitor themes, identify trends, and implement actions to improve safety. This supported a culture of continuous learning and improvement while ensuring people were supported to take positive risks, maintain their independence, and achieve their personal goals.

One staff member emphasised the value of reflective practice and shared learning, telling us, “Learning from incidents is very important for the service and the people we support. Lessons learned are shared across teams, which helps us make improvements and continually enhance the quality of care we provide.”

We scored the service as 3. The evidence showed a good standard of care.

People felt supported throughout periods of transition, including when accessing, transferring between, or being discharged from services. Staff recognised that changes in care arrangements could be a source of anxiety and took steps to provide reassurance and continuity. Information about care and treatment was made available in formats tailored to people’s individual communication needs, helping them to understand and engage with the process.

Staff had effective systems and processes in place to support safe referrals, admissions, transfers, and discharges. Referral information, including clinical histories, risk assessments, and existing care plans, was reviewed comprehensively to ensure the service could meet people’s needs safely and effectively. Staff demonstrated a clear understanding of the importance of thorough assessment and information-sharing to support safe and person-centred care.

Leaders promoted early planning and effective communication between teams and partner organisations to ensure smooth transitions. Discharge planning was coordinated with relevant health and social care services, including specialist community teams, to promote continuity of care and reduce the risk of avoidable delays. Staff worked proactively with external agencies to support timely, safe, and well-managed transitions.

The service followed a structured assessment process, with comprehensive assessments completed and reviewed regularly to reflect people’s changing needs. Staff involved people, and where appropriate those important to them, in planning their care, treatment and support. Information gathered throughout assessments and reviews informed ongoing care planning, risk management, and treatment interventions, ensuring care remained safe, responsive, and focused on achieving the best possible outcomes.

We scored the service as 3. The evidence showed a good standard of care.

People felt safe using the service and were confident that any concerns they raised would be taken seriously and acted upon. Staff encouraged people to share their views and experiences through regular interactions across teams and during daily community meetings, ensuring people were listened to and involved in decisions about their care and support.

Staff demonstrated a good understanding of safeguarding processes and were able to identify, report, and respond to safeguarding concerns in a timely and effective manner. We saw evidence that concerns relating to abuse, neglect, discrimination, or potential harm were managed effectively, with referrals made to external agencies, including local authority safeguarding teams, when required. Safeguarding was embedded within the service’s culture and was routinely discussed during daily handovers, multidisciplinary team meetings, and safeguarding forums. Staff had access to support and guidance from designated safeguarding leads.

Staff demonstrated knowledge of key legislative frameworks, including the MentalCapacity Act 2005, the Mental Health Act 1983, the Deprivation of Liberty Safeguards (DoLS), and the Equality Act 2010. They were able to explain how these frameworks informed their practice and supported people to understand and exercise their rights.

Leaders ensured staff had the knowledge, skills and confidence to recognise and respond appropriately to safeguarding concerns. Staff demonstrated a clear understanding of safeguarding processes and their responsibilities to protect people from harm. One staff member told us, “I support my colleagues to ensure all safeguarding concerns are raised and reported to the appropriate authorities. We carry out thorough investigations with managers support with these processes.”.

The service had robust safeguarding systems, policies, and procedures in place, which upheld people’s human rights and promoted a culture of safety. A review of the trust’s internal allegations against staff spreadsheet for learning disability (LD) services, autism diagnostic services and enhanced support and liaison service (ESLS) found no allegations against trust staff during the reporting period. No cases from March 2026 were identified as continuing into April 2026.

A review of the providers electronic incident reporting system records, and safeguarding screening tools showed that services had identified and responded to a range of safeguarding concerns. These included community-based sexual abuse and exploitation, domestic abuse risks, allegations involving another provider, violence and harassment involving family members, non-recent abuse, and safeguarding concerns relating to children connected to people using the service.

Safeguarding activity included Section 42 enquiries relating to physical and sexual abuse, domestic abuse responses, referrals to adult safeguarding, and involvement of relevant agencies where required. Services also recognised child safeguarding processes, including children who were in care, subject to child protection plans, child in need arrangements, or supported through the team around the family service.

During the reporting period, no patient safety incident investigations were undertaken for learning disability services, the autism diagnostic pathway or ESLS.

One patient safety review was completed during this period. The details and outcome of this review were recorded separately and were available as supporting evidence.

Learning identified through the system engineering initiative for patient safety approach was collated and shared through the service-learning bulletin. This supported wider dissemination of learning across teams and promoted ongoing improvement in patient safety practice.

We scored the service as 3. The evidence showed a good standard of care.

Staff demonstrated a clear understanding of people’s individual specific risks, enabling them to respond promptly and effectively to minimise distress and reduce potential harm. We reviewed 12 risk assessments and found these to be person-centred, with clear involvement from the individual and, where appropriate, their families. Risk assessments were reviewed in line with organisational policy. One family member told us, “The staff are really very good, me and my partner are included in everything. We really feel listened to and heard.”

Staff used a person-centred and proportionate approach to identifying, understanding, and managing risk. Risk assessment and safety planning were carried out collaboratively with people, their families, carers, and relevant professionals where appropriate. Staff focused on understanding each person’s individual needs, communication style, sensory preferences, strengths, triggers, and protective factors to support positive risk management.

The psychology team supported the development of personalised safety summaries with people using the service. These were developed instead of relying solely on generic risk stratification tools and were informed by the 5 Ps formulation model: presenting, predisposing, precipitating, perpetuating, and protective factors. This helped staff develop a holistic understanding of each person’s circumstances and ensured risk management plans were tailored to individual needs.

Care records showed people were involved in discussions about risks and safety planning wherever possible. Families and carers were also involved when appropriate and where consent had been provided. Multidisciplinary team reviews supported shared decision-making and helped ensure that risk plans were regularly reviewed and updated. Where families or carers could not attend meetings in person, staff supported their involvement through virtual meetings via video calls.

Staff used accessible communication methods to help people understand and be involved in managing risks. This included easy-read information, visual resources, pictorial formats, and emoji-based tools where appropriate. Staff across the multidisciplinary team, including psychology, supported people to recognise risks, learn coping strategies, and develop positive ways to manage distress.

Risk management plans promoted people’s rights, dignity, independence, and quality of life. Staff balanced safety with the least restrictive approach and avoided unnecessary restrictions. Any restrictions in place were based on individualised risk assessments, clearly documented within care and treatment plansand regularly reviewed to ensure they remained necessary and proportionate.

Staff promoted a reducing restrictive practice approach, supported by positive behavioural support. This focused on early intervention, proactive support, and understanding the reasons behind complex mental health needs when people expressed distress or agitation. Staff responded to distress in a calm, respectful, and measured way, using de-escalation techniques to reduce the likelihood of escalation.

We scored the service as 3. The evidence showed a good standard of care.

People accessing the service were able to use a range of trust facilities and environments that supported the safe delivery of care. Areas used by people were clean, well maintained, appropriately equipped, and designed to promote individuals’ physical, psychological, and emotional wellbeing. Equipment was subject to regular checks and audits, maintained in accordance with relevant guidance, and stored securely when not in use.

Staff completed environmental safety and security checks at the beginning of each day and before and after appointments to identify and address any potential hazards. Outcomes from checks were communicated through team handovers and daily meetings to ensure risks were shared and managed effectively. Responsibilities for completing environmental checks were clearly defined, supporting a consistent and accountable approach to maintaining safety.

Ligature risks were assessed and managed appropriately. CCTV systems were utilised to support observation, reduce blind spots, and enhance the safety of both people using the service and staff.

The service had effective systems in place to monitor the safety and maintenance of its premises, equipment, and technology. Staff demonstrated a good understanding of environmental safety and were able to describe how they considered physical, psychological, sensory, and sexual safety when supporting people. This helped to ensure environments remained safe, supportive, and responsive to the needs of people using or visiting the service.

We scored the service as 3. The evidence showed a good standard of care.

People using the service received support from sufficient numbers of suitably skilled and experienced staff. Staffing levels and skill mix were reviewed regularly to ensure they reflected the needs, risks, and complexity of people using the service. Leaders adjusted staffing where required in response to changes in people’s needs, including increased risk, enhanced support requirements, or changes in clinical presentation. It was noted that the LD South, LD West, LD East, autism diagnostic services and ESLS were not required to be within safe staffing establishment reporting requirements.

People and relatives told us staff were available, approachable, and responsive. One relative told us, “There is a big team involved with the care of our son. They are really engaging and always supportive when we call or visit places for appointments. I can honestly say the staff do all they can and there is nothing that they could do more for all of us”.

Staff were visible and accessible across the service and worked in a way that supported safe, person-centred care. Where people required enhanced observations or additional support, staffing arrangements were planned to ensure this was delivered safely and consistently. Staff welfare was also considered, with arrangements in place to support colleagues undertaking observations, including welfare checks and support with comfort breaks where needed.

There was appropriate clinical and medical oversight in place. Medical staff were available to provide advice and respond promptly to urgent or emergency situations. Staff understood escalation processes and knew how to access additional medical support when required.

Leaders used rotas, workforce data, and regular reviews to monitor staffing levels, vacancies, sickness, and turnover. The information we reviewed did not identify concerns about staffing capacity.

During June 2026, LD south, LD west, LD east and autism diagnostic services were staffed entirely by substantive staff, with no bank or agency staffing used during the calendar year to date. ESLS used a small amount of bank staffing in June 2026, equivalent to 0.4 whole time equivalent (WTE), representing 2% of the team’s total WTE. This was made up of 0.27 WTE nursing and 0.13 WTE administrative support.

Use of temporary staffing was kept to a minimum and was only used where required to maintain safe and effective service delivery. In June, increased sickness absence at 2.44% and vacancies at 8.83%, alongside ongoing recruitment processes, meant that limited bank staffing was required to maintain the service provision. This was particularly important for ESLS, as timely intervention was essential to support people using the service who were at significant risk of hospital admission or placement breakdown.

Temporary staff completed induction, mandatory training, and were familiar with the service environment, local procedures, and the needs of people using the service. Competency assessments, including observational competencies, were completed to support safe practice.

Recruitment processes were robust and ensured staff were safely recruited. This included appropriate pre-employment checks, enhanced disclosure and barring service (DBS) checks, and confirmation that staff were suitably qualified, experienced, and competent for their roles. Processes relating to conduct, capability, and disciplinary matters were applied consistently and reviewed appropriately.

Staff told us they felt supported by leaders and had access to regular clinical and managerial supervision. Group supervision was also available across the multidisciplinary team, supporting reflective practice, shared learning, and consistent approaches to care. Annual appraisals and personal development reviews had been completed across the services. At the time of assessment, overall compliance was 89.77% for appraisals, 91.95% for management supervision and 86.67% for clinical supervision.

Staff completed mandatory training relevant to their roles, with an overall compliance rate of 89.96% across all teams. It was noted that some teams were small in size, with only one or two staff members required to complete specific training modules, depending on their role requirements. As a result, where one staff member had not been compliant, this had a disproportionate impact on the overall percentage compliance rate. This was considered when interpreting training compliance data for smaller teams.

Staff had access to ongoing learning and development opportunities, and leaders addressed any concerns about performance promptly and effectively.

We scored the service as 3. The evidence showed a good standard of care.

People using the service felt confident in the infection prevention and control measures in place and felt reassured that staff were taking appropriate steps to protect them from the risk of infection. One person told us, “When we do visit services it’s always clean. When the staff visit our home, they will wear masks and gloves when they need to.”

Staff adhered to infection prevention and control (IPC) procedures and demonstrated a good understanding of the measures required to reduce the risk of infection. This included following effective hand hygiene practices, using personal protective equipment (PPE) appropriately, and cleaning equipment in accordance with local policy and best practice guidance. We observed staff consistently followed IPC procedures between appointments and interactions, including appropriate handwashing, changing PPE where required, and disposing of waste safely.

All service environments were clean, tidy, and well maintained. Cleaning schedules and records were completed and up to date, providing assurance that regular cleaning and monitoring processes were in place. Staff understood their responsibilities in maintaining a clean and hygienic environment, and hand sanitising facilities were readily available throughout service locations to support good infection control practices and minimise risks to people, visitors, and staff.

Information relating to infection prevention and control was communicated effectively to staff and shared with people using the service, visitors, and partner agencies where appropriate. Roles and responsibilities for IPC were clearly defined, and staff received regular training and updates to ensure their knowledge and practice remained current and in line with organisational requirements.

We scored the service as 3. The evidence showed a good standard of care.

Staff supported people to be involved in decisions about their medicines and treatment wherever possible. People with capacity were provided with information about their prescribed medicines in a way they could understand and were actively involved in discussions regarding their treatment and any proposed changes. Where people lacked capacity to make specific decisions, staff followed the requirements of the Mental Capacity Act 2005 and the Mental Health Act 1983, ensuring decisions were made in their best interests. Care records reflected individuals’ levels of understanding and demonstrated how people were supported to participate in decisions about their medicines and care.

Staff managed medicines in line with national guidance and best practice. People and, where appropriate, their families or carers were involved in discussions about treatment options to support informed decision-making. The service routinely monitored the effectiveness and potential side effects of medicines, including regular physical health monitoring for people prescribed antipsychotic medication. Staff demonstrated an understanding of the principles of stopping over-medication of people with a learning disability, autism or both (STOMP), and prescribing practices reflected a person-centred approach to medicines optimisation. A review of prescribing and medicines management records identified no concerns regarding the safe use of medicines.

Learning from medicines-related incidents was shared through established trust processes. This included feedback to the staff involved by team managers, and wider learning shared through the trust-wide pharmacy bulletin, which included medicines safety lessons learned and was published every two months.

Staff received appropriate medicines management training and competency assessments relevant to their roles. This supported the safe, effective, and appropriate use of medicines and helped ensure people received treatment in line with their assessed needs and current best practice guidance.

The medicines safety officer confirmed that there had been no medication errors reported for LD south, LD west, LD east, autism diagnostic services or ESLS during the reporting period.