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

Safe Commentary

This means we looked for evidence that people were protected from abuse and avoidable harm
At our last assessment we rated this key question as good. At this assessment the rating has remained the same.

This service scored 66 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Ward team meetings were not consistently held, recorded or followed a standard agenda. We found limited learning from incidents and complaints and evidence of change as a result of patient feedback.

The service did not report any serious incidents during the 12 months prior to this assessment, however there had been 20 instances whereby patients had come to moderate harm. 14 related to pressure area care and 6 related to falls. These incidents had been investigated.

Staff we spoke with knew what incidents to report and how to report them and understood the duty of candour. Staff received some feedback from investigation of incidents.

The service’s referral and admission processes did not always ensure that all essential information about the patient was received to determine if the patient’s needs could safely be met. This was based upon a “trusted assessment” between the services. Between August 2025 and January 2026 29 patients were readmitted to the acute hospital within 72hrs, staff said this was mainly due to insufficient clinical details being included in the referral documentation. This meant that the receiving ward did not have an accurate account of the patients’ clinical needs prior to the admission.

Staff said they often spent significant amounts of time on non-clinical tasks for example, completing housing and social care documentation.

We saw variances in the way patients being admitted from outside the Lincolnshire Integrated Care Board area were treated. Patients deemed out of area were only admitted to a single room due to the screening requirements for Carbapenemase-Producing Enterobacteriaceae (CPE) whereby patients are resistant to some antibiotics. This was implemented to reduce the potential for the spread of infections, but meant admissions could be delayed due to a lack of single room availability.

We were told there were often delays in the delivery and completeness of equipment to patients’ homes in readiness for discharge, this led to longer stays in hospital.

Staff we spoke with said there were often delays in patients being seen by dieticians and speech and language therapists, they said this was particularly challenging when they were managing patients who were undertaking stroke rehabilitation.

Nursing staff received training specific for their role on how to recognise and report abuse. Compliance rates across wards were 95%. Staff we spoke with gave examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act.

Staff demonstrated how to make a safeguarding referral and who to inform if they had concerns.

We looked at 25 care records; we saw risk assessments were completed in all cases.

Staff involved patients in care planning and risk assessments and recorded this in the care record.

Staff communicated with patients so that they understood their care and treatment, this included access to interpreting services and the use of picture cards

Staff enabled patients to give feedback on the service they received via a feedback form.

Staff enabled patients to make advance decisions when appropriate.

Staff used the National Early Warning Score tool to identify deteriorating patients and escalated them appropriately.

Staff shared key information to keep patients safe when handing over their care to others.

Shift changes and handovers included all necessary key information to keep patients safe. We observed one board round where each patient was reviewed by the multidisciplinary team.

Staff did not always ensure out of date medical supplies were disposed of. On one ward we found out of date glucose control solutions which confirm the accuracy of blood glucose monitoring. This meant that if used, the readings could be incorrect and therefore impact on the patient’s physical health.

Clinic rooms were clean and fully equipped; however, we found some gaps in the recording of fridge and room temperatures as well as some readings being out of range with no evidence of subsequent actions taken. We also found a blood glucose machine with a reagent strip attached which was contaminated in blood, we brought this to the attention of staff who disposed of this appropriately and immediately.

The service had enough suitable equipment to help them to safely care for patients, however on one ward we found chairs in the day room which were too high for safe independent transfers. One patient who had her feet on a portable half step said they needed staff assistance to get out of her chair and this help was not always available which caused her anxiety and distress.

Staff did regular risk assessments of the care environment.

Ward layout allowed staff to observe patients in dormitory accommodation, staff told us they aimed to cohort patients with enhanced needs into one area to aid better observation.

Staff disposed of clinical waste safely.

The service had enough nursing and support staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. Sickness rates over the 3 months prior to our assessment were 3%. Turnover rates over the last 12 months were 8.5% against a target of 9%.

We saw managers secured sufficient bank registered and non-registered staff across the community hospital locations.

Managers regularly reviewed and adjusted staffing levels and skill mix. The ward manager could adjust staffing levels daily according to the needs of patients.

The service had not used agency staff in the 12 months leading up to this assessment.

Staff had received and were up to date with appropriate mandatory training.

Managers accurately calculated and reviewed the number and grade of nurses, nursing assistants and healthcare assistants needed for each shift in accordance with national guidance.

Staff told us the number of nurses and healthcare assistants did not always match the planned numbers, however there was daily matron oversight who deployed staff to areas of greatest clinical need.

The service performed well for cleanliness. Local audits were undertaken on a regular basis, and the results were displayed on notice boards on the wards. Cleaning records were up-to-date and demonstrated that all areas were cleaned regularly.

We observed staff followed infection control principles including the use of personal protective equipment (PPE).

Staff cleaned equipment after patient contact and labelled equipment to show when it was last cleaned.

Staff followed systems and processes to prescribe and administer medicines safely and reviewed each patient’s medicines regularly and provided advice about their medicines.

Staff completed medicines records accurately and kept them up to date.