- SERVICE PROVIDER
Lincolnshire Partnership NHS Foundation Trust
This is an organisation that runs the health and social care services we inspect
Report from 18 February 2026 assessment
Contents
Ratings - Acute wards for adults of working age and psychiatric intensive care units
Our view of the service
Lincolnshire Partnership NHS Foundation Trust provides five acute wards for adults of working age across four locations: Ash Villa in Sleaford (15-bed female ward), Ward 12 in Boston (20-bed mixed ward), and Ellis Ward (20-bed male) and Castle Ward (20-bed female) in Lincoln. For this assessment we carried out on-site inspections of Ward 12, Castle Ward and Ellis Ward on 17 and 18 June 2025. The visit was unannounced, meaning the provider was not informed in advance. We returned to the wards on 01 July 2025 to ensure that action had been taken to address our concerns. Actions had been taken and we noted improvements in these areas. The service was last rated Good in June 2024 under CQC’s former inspection framework. This assessment was completed using the new Single Assessment Framework (SAF) and focused on the key questions of Safe, Responsive and Well-led. The assessment was prompted by concerns raised anonymously. Whilst the Trust had identified issues with repeated legal breaches in the use of rapid tranquilisation and had instigated regular audits of compliance that were reported through the governance structure, escalation processes were not sufficiently swift or robust enough to ensure timely board. Due to the insufficient speed and robustness of escalation processes the Board was unable to enact its duty of candour responsibilities when rapid tranquilisation was given outside the legal framework of the Mental Health Act 1983. Staff were not consistently trained or competent in the legal and clinical requirements for rapid tranquilisation. We identified 32 instances where it had been administered without the required authorisation or recorded consent. The trust investigated these concerns and confirmed there were 26 incidents which related to 8 patients when rapid tranquilisation was administered. The trust determined through this investigation and reviews by the local authority and ICB safeguarding leads no harm was caused to the patient and the intervention was clinically indicated. However, the confirmed the necessary safeguards were not in place. Risk assessments were not always accurate or robust, meaning staff did not have clear guidance to manage current risks. Care plans were often generic and not written in the patient’s own voice, and important assessments - such as an autism diagnosis - were not always reflected. While some patients reported positive support - such as help to continue education or maintain family contact - these experiences were not consistent across the wards. Senior Leaders did not demonstrate capable leadership or strong governance in relation to ensuring compliance with elements of the Mental Health Act 1983 and consistent application of person centred- care through care planning and risk assessments. Some staff reported fear of speaking up despite the Trust having a well promoted Freedom to Speak Up Policy, a dedicated Freedom to Speak Up Guardian, several Freedom to Speak up Champions and has Speaking Up as part of its organisational induction and mandatory training. These failings meant that patients were exposed to avoidable harm, delays in discharge and breaches of their legal rights. We found 3 breaches of regulations 11, 12 and 17. We have taken action in response to these breaches of regulation. We issued the provider with a warning notice for: Regulation 11 (Consent to treatment) Regulation 12 (Safe care and treatment) Regulation 17 (Good Governance) You can find more details of our concerns in the report.
People's experience of this service
Patients described individual staff as kind and supportive, and 5 of the 8 patients said they felt involved in discharge planning, with 1 patient reporting that families and carers were invited where consent was given.
Patients told us that staff had helped them continue their education, including supporting attendance at higher education placements. 3 patients said their involvement in discharge planning was limited and 5 patients told us they had not seen a copy of their care plan.
Concerns about safety were also raised. 1 patient told us the ward felt unsafe and “scary at times” describing a lack of faith in how staff managed conflict between patients. Others commented on the noise levels, saying that alarms and shouting were distressing and increased their anxiety. We were told restricted items were often brought onto the wards. 1 patient said that there were opportunities for feedback to the ward, but not all patients felt able to speak freely if they were anxious in group settings.