Lincolnshire Community Health Services NHS 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

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 were protected from abuse and avoidable harm.

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 that we spoke with told us they, and their loved ones were supported very well and felt staff got to know them, their needs, and preferences. People shared that staff team recognised anxieties and concerns within the family and were able to support the patient and the family by offering talking therapy sessions. People said they were listened to and encouraged to feedback on their experience of care within the service.

Staff had access to a freedom to speak up guardian who was able to offer guidance, support. The guardians promoted a positive and safe environment for staff and patients to be able to have a voice within the service. At the time of our visit no safeguarding concerns had been raised in the last 3 months.

All staff we spoke with said they were supported by managers to raise any concerns they may have, and they felt very comfortable to do this. Any incidents or complaints were always taken seriously, investigated thoroughly with outcomes, feedback was given to all involved in a timely manner. Staff told us they had regular 1:1 supervision, patient safety, team and de-brief meetings to discuss any incidents or complaints and lessons were always learned when required. The Butterfly Hospice and John Coupland Hospital Gainsborough and County Hospital had a 100% supervision compliance rate while the other 3 services had a compliance rating ranging from 73%-86%

Staff assessed referrals into the service to ensure the care and support available was suitable for the patient. When accepting referrals the team were mindful of the patient’s home address to ensure that relatives and carers did not have to travel long distances and so the patient was familiar with their settings. Staff ensured they were always visible and available for the patients. Staff had excellent relationships and communicated well with colleagues both internally and externally to the service to enhance the quality of care, treatment, and support the service provided, and ensured continuity in the patients care journey.

If patients felt concerned about their mental wellbeing or physical health, they were able to approach staff, knowing they would respond quickly and effectively, with compassion, and care. Patients, and all the people involved in their care were included in decision making around their care and treatment when transferring to a different care setting.

Staff at the service and external partners worked as one, enhancing the experience of care for people using the service, whilst maintaining continuity. Partners told us, “The service overall had good insight into the care required along with consideration for both patient and family to provide emotional and clinical support.”.

Leaders across the 5 services would have a daily morning meeting to discuss their services, admissions and where services could share resources to best support staff and patients. Staff involved the patient, their families, and internal and external partners in weekly multi-disciplinary team (MDT) meetings and ward round meetings. These included the specialist palliative team, Macmillan team, St Barnabas Hospice and consultants.

A clear process was in place for raising safeguarding concerns. The provider worked collaboratively with the local authority safeguarding team to discuss progress on investigations. All 5 services had no reports of any safeguarding incidents throughout the months of July, August and September 2025.

Staff demonstrated a strong understanding of safeguarding procedures through our conversations. They clearly knew what to report, how to report it, and who to report it to. Staff were confident in identifying various forms of abuse and recognising associated warning signs. Regular patient safety and safeguarding meetings were well-attended, with key information consistently shared and lessons learned when necessary.

Throughout the assessment, staffing levels were observed to be appropriate to meet patient needs and ensure their safety. Staff consistently engaged with patients and their loved ones in a compassionate and meaningful way, showing genuine care and interest in everyone. Their approach was consistently kind and caring. Safeguarding information was readily available and clearly displayed.

Family members told us they felt safe, supported, and listened to. They shared that the family were supported with potential individual risks identified. Staff members were able to sign post to support groups, therapy groups and offer respite to carers.

Processes were in place to assess, monitor, and manage risks to individuals using the service daily. These included identifying signs of deteriorating health, responding to medical emergencies, and managing behaviours that may challenge. Patients and their loved ones were actively involved in risk management however this was not documented. We reviewed 15 patients care and treatment plans across the 5 end of life services. Although the information within the care plans was accurate, unfortunately they did not show how the patient and their families had been involved. We found little to no personalisation which the Trust and the staff teams were aware of.

Staff consistently told us that ensuring patient safety and wellbeing was their top priority. Their approach was caring, compassionate, and person-centred, always recognising patients and their families as individuals with unique needs and preferences. Staff reported that patients and those closest to them were encouraged to contribute in the care provided. They described how they supported and listened to patients and their loved ones, involving them wherever possible.

Processes were in place to ensure both patient and environmental safety, with regular reviews conducted to maintain effectiveness. These processes clearly identified potential risks and outlined appropriate mitigation strategies to reduce risk levels. Staff carried out routine audits of the environment and equipment, and where improvements were identified, action plans were developed and successfully implemented.

We observed that staffing levels were sufficient to meet the care and observation needs of patients. Staff consistently completed prescribed observations, whether in communal areas or individual bedspaces, based on each patient’s location and observation level. Staffing was more than adequate to support both patients and their families.

The ward office and nurse station were strategically positioned to provide a clear view of the ward, allowing staff to monitor the environment and respond promptly when needed. Several lounges and communal areas were actively used by staff to engage meaningfully with patients and their loved ones. Access to doors was controlled via key or fob systems.

Staff reported that structured processes were in place for checking and auditing the environment and equipment to ensure safety. All equipment was well-maintained and in good working order. Any issues or concerns raised were promptly addressed. Staff participated in comprehensive shift handovers, ensuring continuity of care. Patients were placed on varying levels of observation according to their individual needs and risk assessments. This approach helped maintain patient safety and ensured that care needs were met promptly and effectively.

Family members told us they always felt safe and extremely well supported. They felt well cared for and listened to if they had any concerns and always received support to manage any risk.

The service had established processes to ensure that the correct number of staff—with appropriate training and skillsets were deployed both on the ward and in the community. This approach supported the safety of individuals receiving care and ensured their needs were met efficiently and promptly. Mandatory training compliance for staff across the services was at 96% while compliance for Moving and Handling (MH) Level 2 was currently low at 64%. This was due to a reduction in training delivery following the departure of the Trust’s Specialist Advisor in April 2025 to allow for a full review of requirements. During this time all new employees participated in MH training as part of their induction, and the wards were visited regularly for escalation of any onsite issues and ad hoc bespoke training. Level 1 compliance remained strong throughout at 95%. A comprehensive plan was implemented to restore compliance with the appointment of a Band 7 Clinical Expert who was lead the training redesign.

Safe staffing levels at all services were consistently maintained. It was observed that staffing levels within the Butterfly Hospice, due to the nature of how it is commissioned, does not provide resilience against unexpected staff shortages and patient demand. The trust was aware of this concern, and mitigations were in place such as staff being provided from other services when required.

When additional staffing was required, staff between the 5 services were allocated and regular bank staff familiar with the environment and patients were utilised. All staff underwent thorough pre-employment checks in accordance with service policies and protocols, with updates carried out as needed. The service operated systems for monitoring patient needs, with the flexibility to enhance support if those needs changed.

During our time with the service, staffing levels consistently met the requirements for patient care and observation. Prescribed observations were completed reliably, and staff were available to support patients and their families in a safe and timely manner. Multiple quieter rooms and lounges were used by staff to engage in meaningful interactions with patients and their loved ones. Family members told us that the staff team knew them well and they felt involved and listened to regarding decisions around their loved one’s care and treatment including changes.

Staff reported that they were rarely understaffed and consistently had sufficient team members to meet patient needs. They noted that staffing levels could be increased at short notice in response to changing ward demands, with internal bank staff used to maintain continuity and familiarity. Safety systems, including alarms accessible to both staff and patients, were in place to ensure rapid support when required. Staff confirmed they had completed comprehensive mandatory training, reinforcing their preparedness to respond to various situations.

The ward environment and equipment were observed to be clean, tidy, and well maintained. Cleaning stations were strategically placed throughout the ward and were all in good working order. Fully functional sluice rooms were also clean and operational. Staff were seen practicing regular hand hygiene and changing personal protective equipment (PPE) between interactions with different patients, demonstrating adherence to infection control protocols.

Effective processes were in place to ensure the cleanliness and maintenance of the environment and equipment. These were regularly audited to confirm safety and functionality. The service actively involved patients in identifying and managing infection-related risks, promoting awareness and encouraging independence in maintaining hygiene standards.

Cleanliness audits were completed and reported as part of the Ward Assurance process. The target is a score of 95%. Where this is not met, an action plan was developed, with progress monitored through the ward assurance process. A recent review identified that the full National Standards Cleanliness (NSC) Audit was not fully completed for the past three months on some of the wards, with some parts of the clinical cleaning missing from some of the audits. The Trust acknowledged the gaps in NSC audit completion and had taken steps to address them, including ensuring that NHS property services teams were aware that the audits are to be fully completed. Across the months of June, July and August 2025 all services had a cleanliness audit score between 96%-99% apart from Archer Ward which had a score between 89%-94%, with no data shared for the month of August 2025.

Staff demonstrated strong knowledge of infection prevention and control procedures. They were confident in the steps required to safeguard patients, their families, and the environment, and knew how and when to act. All staff had completed mandatory training in infection prevention and control.

In the event of an outbreak, staff explained that the service would promptly contact external partners and inform family members or carers planning to visit the ward, ensuring transparency and safety.

Staff reported adherence to the service’s medicines management policy, including the six R’s of medication administration: Right patient, Right medication, Right time, Right dose, Right route, and the Right to refuse (where appropriate). Defined roles within the team promoted accountability and ensured safe practice.

Upon patient admission, doctors completed the clerking-in process, which included the formulation of a medication chart.Medications were supplied and managed by the local pharmacy, which conducted multiple visits each week. Pharmacists and pharmacy technicians were responsible for checking stock levels, expiry dates, and ensuring appropriate storage of medications. Controlled Drugs (CDs) were managed by the nursing team, who oversaw their safe storage, ordering, and destruction. Medicines reconciliation was carried out promptly, and observations were completed as prescribed, depending on the medication administered. Patients received information leaflets regarding their care, treatment, and medications, which were discussed during multidisciplinary team (MDT) meetings with patients and their families. Medication reviews were conducted regularly.

Feedback from an external professional team stated, “A number of mitigations have been implemented including better access to prescribers for control drugs (CD’s) and more access to just in case medications. The combination of the clinical assessment service and palliative single point of access pilot in Macmillan appear to be having a positive impact on the service.”

Clinic rooms and medicines fridges were clean, well-organised, and equipped with all necessary resources. Medicines were stored, managed, and dispensed in accordance with national guidance, including protocols for controlled drugs. Staff had access to comprehensive patient medication documentation, including allergy information.

All medication errors were logged on Datix system used by the trust.Learning was cascaded from individual reflection through case-based discussion, to team-level huddles, Friday feedback emails and across the organisation via steering groups with confirm and challenge methodology and fed into the ward level Quality Improvement plans, seven-minute briefings, and the Trust’s Medicines Safety Oversight Group.

Following a detailed review all medicine related Datix submissions in the last 3 months, only one error was identified as directly relating to End of Life (EOL) care within the community hospitals and one in the Butterfly Hospice.