- SERVICE PROVIDER
Lincolnshire Partnership NHS Foundation Trust
This is an organisation that runs the health and social care services we inspect
Report from 12 January 2026 assessment
Contents
Ratings - Long stay or rehabilitation mental health wards for working age adults
Our view of the service
The Vales is a female only ward that has 15 beds. It specialises in providing rehabilitation to people who are suffering with long term mental health disorders, including person’s detained under the Mental Health Act 1983.
We visited the Vales on 17 and 18 September 2025 and again on 1 October 2025 in response to concerns about patient and staff safety.
The Fens is a male only ward that has 15 beds. It specialises in providing rehabilitation to people who are suffering with long term mental health disorders, including person’s detained under the Mental Health Act 1983.
The Fens was visited as part of this inspection on the 18 September 2025.
The ward environment was clean, well maintained and suitable for the needs of the patient group. Staffing levels generally met the planned establishment, Medicines were managed safely, and infection prevention and control standards were good.
Whilst leaders on the Vales had taken steps to strengthen physical-health monitoring and oversight through new assurance processes and daily checks, these were not embedded. This placed patients at risk. Staff were not all trained or competent in essential clinical skills such as neurological observations and enteral feeding, and gaps in physical-health monitoring continued despite recent improvement initiatives. Incidents involving ligatures, assaults and airway obstruction continued to recur, and the severity of harm was sometimes underestimated in incident grading. This limited the ward’s ability to recognise risks, learn effectively and prevent recurrence.
The Vales had developed a quality improvement plan to strengthen governance, culture and staff competence. While this plan provided structure and oversight, many actions were still in progress with completion dates extending into 2026. Learning from incidents, safeguarding enquiries and physical-health concerns was not yet embedded into governance or daily practice. Repeated issues with record keeping, nutrition and hydration monitoring, and escalation of deteriorating health remained evident across care records and assurance documentation.
Leadership visibility and accountability on the Vales had improved following the appointment of a new clinical lead, service manager and improvement lead. Governance structures were in place, including daily oversight meetings and regular reporting to the Quality Review Meeting and Performance and Delivery Oversight Group. Leaders were honest about the challenges faced by the service and demonstrated commitment to improvement. However, governance, culture and learning systems were not yet mature enough to ensure that improvements were sustained, embedded or that care was consistently safe and high quality.
Due to the level of risk identified, the Care Quality Commission issued a Notice of Proposal (NOP) under Section 12 of the Health and Social Care Act 2008, requiring the trust to improve staff competence in physical-health monitoring, strengthen daily assurance processes, independently review incidents of harm, and enhance board-level oversight and learning on the Vales. We found breaches in regulations 12, 14, 17 and 18.
People's experience of this service
Most people told us that staff were kind, caring and tried their best to support them. We observed positive interactions where staff spoke calmly, used respectful language, and offered reassurance.
However, people’s experiences of care were not consistent. Some patients said they did not always feel listened to or respected. One patient told us they felt “worthless” after a negative interaction with a staff member, and another was afraid to raise concerns because of how their feedback had been received previously. A further patient reported language barriers made it difficult to communicate their needs and to feel understood.
One patient described feeling unsafe after being assaulted by another patient.
Despite these challenges, patients recognised that most staff were doing their best in a difficult environment. Advocacy services were available, and patients had been supported to understand their rights under the Mental Health Act.
Overall, people’s experiences of care were mixed. While many staff treated patients with kindness and compassion, inconsistency in communication and care planning meant that not everyone experienced care that was respectful, inclusive or fully person-centred.