Lincolnshire Community Health Services NHS 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

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

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.

Patients were assessed to deliver care and treatment for all individuals using the service. This included, where appropriate, attention to their nutritional needs, hydration, and pain management. Procedures were in place to carry out admission assessments but were lacking individualisation, including care plans being written in a person-centred way. Staff understood and valued the patients voice but shared that they felt let down by the systems that created the care plans, they were described as accurate but lacked personalisation which was evident when we reviewed patient care plans.

Staff expressed pride in the way care was provided, and this ethos was actively promoted by the service. Evidence-based practices and technologies were employed to support the delivery of high-quality care. Patients and their loved ones were consistently encouraged and supported to participate in care planning and risk assessments.

Palliative Single Point of Access (PSPA) is a dedicated phone line for patients who required urgent advice / support for unplanned care needs. Depending on their need this could be advice and guidance, home visits or medication prescription. From August 2025, the PSPA is now a jointly delivered model between Macmillan Community Specialist Nurses and the Clinical Assessment Service (CAS) whereby one Macmillan nurse took calls remotely and one Macmillan nurse sat with CAS and supported CAS with the calls. This increased the specialist nursing coverage to 8am to 8pm seven days a week. Hours outside of these hours would continue to be provided by the CAS team.

An external professional related to patient referrals shared, “Discussions include if the person is eligible for Fast track including the confirmation of preferred place of death if appropriate. Additionally what level of care is required is also discussed, for example how many care calls are to be provided if night care is required.”

The service ensured that individuals received care, treatment, and support that were grounded in evidence-based practices and aligned with recognised standards of good care. Systems were in place to keep staff informed and compliant with current national legislation, best practice guidelines, and required professional standards. Patients who used the service were actively informed about relevant good practice approaches and were involved in how these were incorporated into their care. This collaborative approach supported transparency and empowered individuals in their care journey.

The nutritional and hydration needs of individuals were met in accordance with current clinical guidance. Staff were trained to assess and respond to these needs effectively, ensuring that care plans reflected up-to-date recommendations and individual preferences, however when reviewing patients care plans, there little evidence of any patient involvement.

Staff and leadership were encouraged to engage with new approaches that had been shown to enhance care delivery. Staff supported patients to understand their treatment and had good knowledge of the communication resources, and options available to them. The service promoted a culture of learning and improvement, supporting the adoption of practices that improved outcomes and experiences for people using the service. Family members shared that they were always able to speak to staff about the care and treatment of their loved ones.

Staff demonstrated meaningful engagement with patients and their loved ones, actively supporting the involvement of external partners when appropriate. They were consistently present and available on the ward, participating in activities alongside patients to foster connection and support. Information relating to care, treatment, support, communication needs, activities, and feedback was clearly displayed throughout the ward, ensuring accessibility for all.

Staff reported having access to the necessary resources and guidance to deliver high-quality, person-centred care. The service maintained strong working relationships with external partners and care providers involved in each patient’s treatment journey. These partners were routinely invited to care and treatment reviews to promote continuity of care, whether for planned discharge or transition to another care setting.

Family members told us that they could speak to staff about the care and treatment provided and receive correct and accurate information. They found that the patient care was well coordinated, and everyone involved in their care worked well together and with them. One family member told us, “They provided whatever we needed and respected our choices and preferences. There were not any restrictions on what we couldn't do or wasn't allowed to do.”

The Community Macmillan team provided a community Nurse Specialist service to palliative care patients. The Community Macmillan Team made 8,773 contacts within the last 12 months (September 2024 – August 2025), these were both face to face and non-face to face contacts.

Teams across the service were committed to collaborative working and had adopted innovative and efficient approaches to deliver more integrated care. Discharge, transfer, and transition planning was approached holistically and initiated at the earliest possible stage. Care and treatment plans were developed through a multi-disciplinary process and reviewed weekly, or sooner if a patient’s needs changed, during structured ward review meetings.

Staff consistently supported individuals to lead healthier lives through a proactive and targeted approach to health promotion and illness prevention. They maximised every interaction with patients to identify those requiring additional support and to provide guidance on healthier lifestyle choices, including nutrition and hydration.

The service had established processes to ensure that patients and those who knew them well had access to specialist advice and support always tailored to their needs.

Staff reported that they actively encouraged patients and their loved ones to be involved in decisions about care and treatment. They supported individuals in making informed choices and promoted healthier behaviours wherever possible. Patients and those important to them were engaged in monitoring health and were encouraged to participate in relevant assessments to support this.

Staff were actively involved in monitoring and improving the quality of care and outcomes for individuals, including tracking progress for those who had transitioned to other services. The service proactively engaged in benchmarking activities, peer reviews, and recognised accreditation schemes to maintain high standards. Outstanding performance was acknowledged by credible external organisations, and outcomes for people using the service remained consistently positive.

The trust used The NHS Friends and Family Test (FFT) feedback tool that allowed patients to provide quick, anonymous feedback about their experiences with NHS services. It aimed to help service providers and commissioners understand patient satisfaction and identify areas for improvement.

Staff reported adherence to relevant legislation and best practice guidelines. Assessments and treatments were evidence-based and routinely evaluated for effectiveness. Continuous monitoring of patients’ needs enabled staff to refine and enhance care delivery. Learning from both positive outcomes and adverse events was embedded into practice, contributing to ongoing service development and improvement.

The Trust actively benchmarked its palliative and end of life care services against national standards and frameworks to ensure safe, effective, and compassionate care.They use the National Audit of Care at the End of Life, Lincolnshire Palliative and End of Life Care Alliance, NICE Guidelines and the Gold Standards Framework in which Scotter ward within John Coupland Hospital Gainsborough received a Gold Standards Framework Accreditation in 2024 for the palliative care they provided. All other services have shared that they were also striving towards this accreditation.

Processes related to consent and record-keeping were actively monitored and reviewed to enhance how individuals are involved in decisions about their care and treatment. Engagement with stakeholders including people who use the service and those close to them played a key role in developing tools and resources that support informed consent.

Care and treatment plans, along with assessments, were documented in patient records. These records were accurate but did not reflect the person-centred approach that was being delivered. There was little evidence of any input from patients those who knew them well.

Staff reported that they followed the principles of the Mental Capacity Act 2005 and ensured that consent to treatment was obtained appropriately. Patients and their loved ones were encouraged and supported to contribute to care and treatment planning. Where concerns about a patient’s capacity to consent were identified, appropriate assessments were carried out and reviewed regularly.

Family members told us that the staff team were very respectful and patient with all the family including their loved one. They said the staff listened to them and were very patient and understanding when sharing information. All that were involved understood that it was a difficult time for all the family.