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, fair culture. This key question has been rated good.

This service scored 79 (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.

Results from the most recent staff survey had varied responses from the staff members who participated. During our assessment all staff members who were interviewed shared positive feedback and did not raise any concerns. Leaders were aware of the recent staff survey results and shared that the care group had undergone significant change, which had affected some areas of staff experience and morale. Leaders had acknowledged this and were using staff feedback to support improvement. trust-wide and local actions were in place to improve wellbeing, leadership, communication and psychological safety, including team discussions and the development of team charters to strengthen shared expectations and team culture.

Staff and leaders described a clear and shared vision for the service, which focused on delivering safe, effective, compassionate, inclusive, and person-centred care for people with learning disabilities and autistic people. The service promoted a culture where people were placed at the centre of care and treatment decisions, and where support was shaped around individual needs, strengths, preferences, communication styles, and personal goals.

Leaders promoted an open, supportive, and inclusive culture. Staff t felt able to raise ideas, discuss concerns, and contribute to the ongoing development of the service. Leaders were visible and approachable, and staff described feeling valued and listened to. This fostered a positive working environment where staff felt confident to reflect on practice, share learning, and work collaboratively to improve outcomes for people and their families.

They understood how their individual roles contributed to the wider aims of the service, including promoting independence, reducing health inequalities, supporting recovery, and improving people’s quality of life.

Leaders ensured the service’s vision, values, and priorities were communicated effectively through induction, mandatory training, supervision, team meetings, governance forums, and ongoing professional development. These systems helped staff understand their responsibilities and maintain a consistent approach to care delivery across the multidisciplinary team.

Staff were actively engaged in discussions about service priorities, improvement work, and changes within the team. Leaders encouraged staff involvement during periods of service development or transformation, which helped promote ownership, shared accountability, and a common understanding of the service’s direction. Staff were supported to contribute ideas and identify opportunities to improve care and support.

Communication across the service was consistent and effective. Leaders used regular meetings, supervision, service updates, and governance structures to share key information, reinforce priorities, and maintain a clear sense of direction. This supported effective teamwork and helped ensure staff worked together towards shared goals.

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

Leaders had the skills, knowledge, and experience needed to manage the service effectively. Roles and responsibilities were clearly defined, and leaders understood their accountability for service quality, safety, performance, and improvement. They maintained oversight of key issues, risks, concerns, and service priorities through regular communication with staff and established governance processes.

Leaders demonstrated a strong understanding of the needs of people with learning disabilities and autistic people, including the importance of reasonable adjustments, accessible communication, person-centred care, and reducing health inequalities. They supported staff to deliver safe, effective, compassionate, and inclusive care that reflected people’s individual needs, preferences, strengths, and goals.

Leaders modelled compassionate and inclusive behaviours that reflected the organisation’s values and promoted dignity, respect, equality, diversity, and human rights.

Leaders supported staff development and encouraged progression within the service. Staff had access to training, supervision, and career development opportunities relevant to their roles. There were examples of staff being supported to progress through apprenticeship pathways, including care support workers completing further qualifications and being encouraged to apply for nurse training where this matched their career aspirations.

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

The service had clear freedom to speak up (FTSU) policies and procedures in place. Staff had access to the organisation’s freedom to speak up guardian, as well as designated freedom to speak up champions within the service. These staff were visible and available to provide advice, guidance, and support to colleagues who wished to raise concerns.

Staff understood how to raise concerns and were encouraged and supported to speak up. Leaders promoted an open, transparent, and psychologically safe culture where staff felt able to raise concerns without fear of blame or reproach. Staff said leaders listened to concerns, acknowledged them appropriately, and took action where required. Concerns were investigated in line with organisational processes, and staff who raised issues received updates about outcomes and any actions taken.

Staff received training in whistleblowing and freedom to speak up, which supported their understanding of how to raise concerns and the support in place if they did so. Leaders reinforced the importance of speaking up through supervision, team meetings, and governance processes. Freedom to Speak Up was also discussed in staff supervision when relevant, ensuring staff had regular opportunities to raise issues in a safe and supportive setting.

Freedom to Speak Up matters were monitored through governance meetings and monthly team meetings. Contacts and concerns were reviewed and audited to identify themes, trends, or areas for improvement. Where themes were identified, action plans were developed and monitored to ensure improvements were made.

Staff felt confident that concerns would be taken seriously and acted on appropriately. This supported a culture of openness, learning, and continuous improvement.

During the period of April, May and June 2026 four freedom to speak up concerns had been raised by staff. The themes related to leadership style and concerns about service changes. Three of the four concerns related to the same individual within the learning disability service. These concerns had been reviewed and were being managed through appropriate HR processes, with oversight from the director of operations. Support arrangements were in place to ensure the matters were addressed effectively.

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

The service demonstrated a clear commitment to promoting equality, diversity and inclusion across the workforce. Leaders promoted a culture where staff were treated fairly, respectfully and with compassion. Staff told us they felt valued, listened to and recognised for the contribution they made to the service.

Leaders had oversight of workforce culture and took steps to identify and address any concerns relating to unfair treatment, discrimination or inequality. This included considering the experiences of staff with protected characteristics and those from marginalised or underrepresented groups. Reasonable adjustments and flexible working arrangements were supported where possible to meet individual staff’s needs and promote an inclusive working environment.

Equality, diversity and inclusion principles were embedded within the organisation’s values and was reflected in the way staff worked with each other, people using the service, families and carers. Staff completed mandatory training, including equality, diversity and inclusion and unconscious bias training. This helped staff understand the impact of discrimination, inequality and unconscious bias, and supported respectful and inclusive practice.

Leaders promoted an inclusive culture by recognising and celebrating cultural and religious diversity. The service held events and activities that encouraged staff and people using the service to learn about and celebrate different cultures and traditions. For example, during cultural awareness week,inpatient staff members prepared meals from different cultures, which staff and people using the service shared together. These activities helped promote understanding, inclusion and positive relationships.

Recruitment processes were designed to be fair, timely and equitable, in line with the Equality Act 2010 and organisational policies. This supported the development of a diverse workforce that reflected the communities served by the service.

Leaders promoted a zero-tolerance approach to bullying, harassment and discrimination. Staff were encouraged to speak up, share their views and contribute to service development, including those who may be less likely to have their voices heard.

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

Leaders had effective governance and management arrangements in place to support the delivery of safe, high-quality and sustainable care for people using the service. Governance systems provided clear oversight of quality, safety, risk, performance and service improvement. Staff understood their roles and responsibilities and were supported to work within clear lines of accountability.

The service had regular and structured meetings to review key areas of practice, including risk, incidents, safeguarding, complaints, referrals, waiting lists, caseload pressures, care planning, transitions and the quality of care being provided. Daily handovers and team discussions supported effective communication and ensured staff were aware of changes in people’s needs, risks or circumstances. This helped maintain continuity of care and supported timely decision-making.

Leaders promoted a culture of learning and continuous improvement. Staff were involved in audits, reviews and quality assurance processes, and findings were used to improve practice. Where areas for development were identified, action plans were developed, monitored and reviewed to ensure improvements were made and embedded. This supported ongoing service development and helped ensure care remained responsive to people’s needs.

Leaders maintained oversight of risks through clear risk management processes, including an up-to-date risk register. Risks were regularly reviewed and escalated where needed. Staff understood how to report and escalate concerns, and contingency plans were in place to respond to service pressures, infection outbreaks, staffing issues or other disruptions. This helped ensure the service remained safe and resilient.

Information systems supported staff to record, access and share relevant clinical information safely and effectively. Information governance arrangements were in place to ensure personal information was managed securely and confidentially. Staff understood their responsibilities in relation to confidentiality, data protection and record keeping.

Leaders had access to accurate and timely performance and quality data, which supported effective oversight of the service. This included information relating to incidents, complaints, safeguarding, training, supervision, audits, staffing and service activity. Statutory notifications were submitted to external organisations, including the care quality commission, in line with regulatory requirements.

The service used recognised quality improvement approaches to support innovation, learning and sustainable service development. Leaders balanced improvement work with proportionate risk management, ensuring changes were planned, monitored and evaluated.

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

Staff worked collaboratively across the multidisciplinary team and with external partners, including primary care, social care, local authorities, advocacy services, acute hospitals and specialist providers. These working arrangements supported coordinated care, effective risk management and smooth transitions between services. Information was shared appropriately to ensure people received the right support at the right time.

Staff and leaders worked effectively with partner organisations and community services to support integrated, person-centred care. The service had established relationships with commissioners, local authority teams, social care providers, primary care, specialist mental health services, advocacy services, and other relevant agencies. These partnerships supported coordinated care, timely information sharing, and improved outcomes for people and their families.

Leaders promoted an open and transparent approach to partnership working. They engaged with external stakeholders to share learning, manage risks, and identify opportunities to improve care and support. Managers attended local quality and safety meetings with partners, including learning disability and autism providers, commissioning colleagues, and police representatives where appropriate. These meetings supported shared oversight of incidents, risks, safeguarding themes, and service developments.

The service contributed to wider local, regional, and national learning disability and autism networks. Leaders and staff used these forums to share good practice, review developments in policy and guidance, and consider how changes may affect people using the service. Learning from these networks was shared within the team and used to inform service improvement, practice development, and the wider learning disability and autism steering group.

Staff were involved in professional forums that supported collaboration and improvement across services. For example, nursing staff participated in national learning disability nursing forums involving NHS and independent specialist providers. These forums provided opportunities to review national priorities, discuss practice challenges, and share learning that could improve the quality and consistency of care.

The occupational therapy team also engaged with local and national professional networks to share learning, updates, and examples of good practice. Staff were involved in wider quality improvement and accreditation forums, which supported benchmarking, peer learning, and the development of more effective care and support for people with learning disabilities and autistic people.

The service encouraged community involvement and supported people to take part in meaningful activities that promoted inclusion, confidence, and wellbeing. People using the service were supported to participate in community initiatives, fundraising activities, and social opportunities.

Leaders actively sought feedback from partners, people using the service, families, carers, and the wider community. Feedback was valued and used to shape service delivery, strengthen partnership working, and identify innovative approaches to improving care.

We scored the service as 4. The evidence showed an outstanding standard of care.

The organisation promoted a strong culture of continuous learning and improvement. Staff and leaders demonstrated a clear understanding of how to implement and sustain change, using structured quality improvement methodologies to enhance care, support and service delivery. A quality improvement programme (QIP) was introduced across the care group in February 2026 following significant engagement with services. The programme brought together learning actions from complaints, patient safety events and other learning activity into one central place. This supported improved oversight, sustainability and access to live and historical quality information for service managers.

The QIP included a learning log, service-level quality plans, benefits realisation, audit planning, and live trackers for complaints, patient safety events and coronial processes. Initial progress focused on ensuring that all actions and plans were captured within the programme. Work was ongoing to strengthen the quality of actions, reduce duplication and ensure actions were realistic, measurable and timely. Expected completion dates were planned to be in place for all actions by September 2026.

“Plan, Do, Check, Act” meetings had been established with the care group quality team to provide oversight, support accountability and monitor progress against actions and quality plans. From August 2026, progress from these meetings was due to be reported by the patient experience and safety Co-ordinator.

An audit gap analysis had also been completed by the patient experience and safety co-ordinator. This identified additional audits that would be beneficial for the care groups and informed the audit plan held within the QIP.

Reasonable adjustments training had been co-produced with experts by experience as part of the reasonable adjustments working group and was being delivered across the organisation. This supported improved awareness and practice in meeting individual needs.

Within ESLS, learning and innovation were supported through talking mat workshops, which helped staff develop confidence and competence in using visual communication tools to improve patient inclusion and engagement. Speech and language therapists and occupational therapists contributed to ESLS bitesize training, including planned collaborative work on sensory integration and future speech and language-related topics. Training was delivered in response to identified knowledge gaps.

The ESLS team also held a monthly journal club, which supported reflective practice, shared learning and ongoing professional development within the team.

The service participated in relevant national audits and benchmarking initiatives and was in the final stages of gaining accreditation with the carers trust triangle of care, a recognised quality improvement programme that promoted effective engagement with families and carers and supported them to be key partners in their loved one’s care.

Staff actively engaged with research and incorporated evidence-based practice into care delivery. Strong links with external partners further supported innovation and service development. Leaders maintained open and transparent communication with staff, fostering a culture of trust where ideas for improvement were encouraged, valued and acted upon.