• Organisation

Leicestershire Partnership NHS Trust

This is an organisation that runs the health and social care services we inspect

Overall: Requires improvement read more about inspection ratings
Important: Services have been transferred to this provider from another provider
Important: Services have been transferred to this provider from another provider

Latest inspection summary

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Overall inspection

Requires improvement

Updated 22 June 2022

We carried out this unannounced inspection of Leicestershire Partnership NHS Trust because at our last inspection we rated two mental health services provided by this trust as inadequate, four mental health services and one community health service as requires improvement. We rated the trust as inadequate for well-led overall.

At this inspection, we visited the two mental health services previously rated inadequate and one mental health service previously rated as requires improvement.

We also inspected the well-led key question at provider level for the trust overall.

At this inspection, two of the three mental health services we inspected improved overall. We rated all three mental health services inspected as requires improvement overall.

At this inspection the overall ratings for mental health services stayed the same in safe, effective and responsive, which we rated as requires improvement. Caring stayed the same, rated as good. The rating for well-led in mental health services, improved to requires improvement.

At this inspection the well-led provider rating improved from inadequate to requires improvement.

We inspected three mental health inpatient services because of the ratings from the previous inspection. All three service inspections were unannounced.

We inspected all key lines of enquiry in all domains (safe, effective, caring, responsive and well-led) in two services. These services were:

  • acute wards for adults of working age and psychiatric intensive care units and
  • long stay or rehabilitation wards for working age adults.

We inspected all key lines of enquiry in two domains (safe and well-led) in a third service. This was:

  • wards for people with a learning disability or autism.

We also assessed if the organisation is well-led and looked at areas of governance, culture, leadership capability and improvement. Our inspection approach allows us to make a judgement on how the trust’s senior leadership leads the organisation and the provider level well-led rating is separate from the ratings of the services we inspected.

We did not inspect the following core services previously rated as requires improvement:

  • community health inpatients services
  • community based metal health services for adults of working age
  • mental health crisis services and health-based places of safety
  • specialist community mental health services for children and young people.

We did not inspect the following core services previously rated as good:

  • forensic inpatient or secure wards
  • child and adolescent mental health wards
  • wards for older people with mental health problems
  • community based mental health services for older people
  • community based mental health services for people with a learning disability or autism
  • community health services for adults
  • community health services for children and young people, and
  • community end of life care.

We are monitoring the progress of improvements to services and will re-inspect them as appropriate.

In rating the trust overall, we took into account the current ratings of the 12 services not inspected this time.

Our overall rating of this trust stayed the same. We rated them as requires improvement because:

  • The trust leadership team had not ensured that all requirements from the last inspection had been actioned and embedded across all services. This meant some fundamental standards were not being met. This included environmental improvements, shared sleeping accommodation, response times to maintenance issues, care planning and access to relevant therapies in certain services. Improvements were noted in some wards in core services but not all. Senior leaders in core services we inspected, had not maintained oversight of improvement across all wards of their services.
  • In two of the core services inspected, the environment had not been well maintained. This was highlighted in the previous inspection. Maintenance teams did not undertake repairs in a timely way and not all areas used by patients were clean. Some patients continued to share bedroom spaces in dormitories, and personal belongings were stored on the floor because of limited storage provided by the trust.
  • Not all patients on acute wards for adults of working age could summon help from staff if required. There was no patient alarm access in four ward areas, including the dormitories. Following inspection, the trust submitted an action plan to review access to call alarms.
  • In all three services, not all staff were up to date with mandatory training. Staff who delivered training had been redeployed away from training during the COVID-19 pandemic, but face to face training had restarted and not all staff who had out of date training had rebooked.
  • Staff had not managed all risks to patients in services. Staff did not always follow trust policies and procedures when they needed to search patients or their bedrooms to keep them safe from harm. Staff on the acute wards were not consistent with searching patients upon return from unescorted leave as some patients had managed to take lighters onto four of the wards. The service did not have a system in place to monitor the number of lighters each ward held. This was an issue highlighted at our inspection in 2018. At the Willows, six out of 19 patient’s risk assessments had not been updated. At the Agnes Unit, staff did not always record the physical health of patients who had been given rapid tranquilisation. In addition, staff did not record the maximum dose of medications a patient could have in any 24-hour period.
  • Patient access to psychology and occupational therapy was less than expected on acute wards and rehabilitation wards due to the number of staff vacancies in therapy positions. The lack of psychology was an issue highlighted at our 2018 inspection.
  • Two core services did not promote patient centred care in all aspects of care delivery. In rehabilitation wards, staff did not always develop and review individual care plans. Not all care plans reflected patients’ assessed needs, or were personalised, holistic and recovery oriented. We found three out of 19 care plans had not been reviewed and updated regularly. On acute wards, not all informal patients knew their rights.
  • Staff did not consistently promote dignity and respect as expected in all services. Curtains were missing from bed spaces and staff did not wait for an answer from patients before entering rooms on acute wards. On rehabilitation wards, staff did not care plan the needs of a patient with protected characteristics. In two services, staff were not always caring towards patients.
  • The trust had not responded in a timely way to eliminate shared sleeping arrangements (dormitories). On four wards in acute wards for adults of working age, there were shared sleeping arrangements for patients. The trust was told to address the arrangements for eliminating dormitories at our last inspection in 2018 and work had started on one ward in March 2021. Whilst there was a plan to eradicate the dormitories across the trust, there were delays to the timetable and patients continued to share sleeping accommodation which compromised their privacy. Following inspection, the trust submitted an action plan to review shared sleeping arrangements.
  • Managers did not successfully cascade information down to all ward staff in acute mental health services. Staff we spoke with were unaware of incidents and learning on other wards across acute wards for adults of working age; this was highlighted as an issue at our inspection in 2018. In the same service, managers did not always review incidents in a timely way.
  • Governance systems and processes, and the strategy of the organisation had been extensively reviewed since our last inspection but was not fully embedded into services. Some managers had access to key performance data and could respond to areas of improvement, but this was not consistent in all aspects of care delivery and across all services. For example, issues found in risk assessments, care plans and environmental concerns had been addressed in some services, but not all since our last inspection.


  • In July 2019, the new trust board formed a buddy relationship with a mental health and community health service NHS trust in Northamptonshire (Northamptonshire Healthcare NHS Foundation Trust – NHFT) following the previous inspections in 2018 and 2019. This became a formal group working partnership in April 2021. A new chief executive was appointed as a shared role between the two trusts. The trust had made significant improvements to develop a strengthened vision and strategy.
  • Following the appointment of a new chief executive a new trust board was formed. We noted how much time the new executive team had invested in making and implementing improvements during the COVID-19 pandemic.
  • The Step up to Great strategy identified key priority areas of focus which were linked to the trust’s vision.
  • Governance processes had improved since our last inspection and operated effectively at trust level to ensure that performance and risk were managed well. There were clear responsibilities, roles and systems of accountability to support good governance and management.
  • A positive culture had developed since our last inspection. Staff told us they felt happy and enjoyed their work. There was good staff morale in services. Staff felt respected, supported and valued and we heard how well the trust supported staff during the COVID-19 pandemic. Leadership behaviours were fostered, and development of staff was encouraged. There was an extensive wellbeing offer available to staff.
  • Engagement with external stakeholders had significantly improved since our last inspection. The trust had key roles in the development of health and social care system working, and collaboration with other care providers to improve provision of mental health services. The trust ensured that people who used services, the public, staff and external partners were engaged and involved in the design of services.
  • Equality diversity and inclusion matters had been a focus of the new trust leadership team.
  • Medication management had improved significantly across the services. There were improved systems and processes to manage storage, disposal and administration of medications.
  • Services had complied with guidance on eliminating mixed sex accommodation. Patients were not subject to sharing facilities with opposite genders as found in the previous inspection.
  • Infection prevention and control (IPC) was well managed and monitored and services were responsive to deal with frequent changes in IPC requirements during the pandemic.
  • Seclusion environments were not an issue of concern at this inspection. Staff documented seclusion well in most services, compared to our last inspection.
  • Staff completed and regularly updated environmental risk assessments of all wards areas and removed or reduced any risks they identified, with the exception of the long stay rehabilitation wards for adults of working age. Staff followed procedures to minimise risks where they could not easily observe patients.
  • Patient involvement in planning care was now in place and the voice of the patient in changes to services had been considered.
  • There was a good working relationship between the Mental Health Act (MHA) administration team and the wards, community teams and the executive team. This had continued during the pandemic.
  • The trust had robust arrangements in place for the receipt and scrutiny of detention paperwork. The scrutiny process was multi-tiered, which included the nurse, Mental Health Act administrator and medical scrutiny. The trust had developed checklists to assist staff with the receipt and scrutiny process.
  • There had been only one out of area placement over 14 months. This was a significant improvement since our last inspection which reported 171 out of area placements lasting between two and 192 days. In rehabilitation services, staff had effective working relations with the new rehabilitation community transition support team created in response to the pandemic to facilitate faster discharges from the wards.
  • Services treated concerns and complaints seriously, investigated them and learned lessons from the results. Managers shared the outcome of complaints with their ward teams.
  • The trust board, heads of departments and senior leaders had access to the information they needed to manage risk, issues and performance across the trust.

How we carried out the inspection

During the inspection, our inspection teams carried out the following activities across 11 wards in the services:

  • reviewed 64 care records
  • reviewed 53 medication records
  • interviewed 73 staff and 13 managers
  • interviewed 35 patients
  • spoke with 15 family members or carers of patients
  • checked 5 clinic rooms
  • attended 5 meetings
  • observed 10 episodes of care
  • reviewed the mental health act detention papers of 23 patients and seclusion records of 10 patients, and
  • received 41 comment cards from patients that were available for patients to complete during the time of our inspection.

During our well-led inspection, we spoke with 32 senior leaders of the organisation and looked at a range of policies, procedures and other governance documents relating to the running of the trust.

You can find further information about how we carry out our inspections on our website: www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

What people who use the service say

On Heather ward patients said that there was not enough ventilation on the wards. The matron opened some vault windows via a remote. They later told us that this had been an ongoing concern for around five years. Two patients told us they had experienced cancelled leave, and numerous staff confirmed that facilitating escorted leave had been difficult at times which had led to either a cancellation, or where possible delayed leave. Three patients told us of times when staff had been rude, threatening and disrespectful towards them.

We spoke with five informal patients at the Bradgate Mental Health Unit who were unaware of what they could and could not do as an informal patient. One patient told us they did not know they could leave the ward to seek medical attention. Beaumont ward did not have a poster displayed around informal patients and rights as a patient had ripped it down.

Two patients we interviewed on Ashby and Heather wards told us that staff did not always knock on their bedroom doors before entering. One patient on Thornton ward told us that while staff did knock, they did not wait for a response before entering, which had resulted in staff walking into their room while they were changing their clothes, compromising their privacy and dignity.

One patient told us that staff had been rude, threatening and disrespectful towards them, which a relative also confirmed. One ward matron told us that a patient had recently alleged that a staff member had assaulted them. Ward matrons were looking into these alleged incidents.

One patient on Watermead ward told us that a staff member had ignored them when they had asked them for a sandwich.

Six further patients across Beaumont, Ashby and Heather wards told us that not all staff were caring or respectful. One patient on Heather ward claimed that they had previously watched a staff member walking past a distressed patient and did not seek to reassure them or ask what was wrong.

We spoke with five patients on long stay or rehabilitation wards; they told us they felt very well supported, and staff and were kind, caring, and respectful. One patient told us there wasn’t enough to do at the Willows. Another patient said on their comment card they did not see enough of the occupational therapist.

We spoke with nine patient families and carers. Some families and carers told us that the service was not responsive, telephone calls to the service were not returned. Not all families and carers knew they could attend virtual ward meetings and care programme approach meetings. Where patients did not access multimedia, families and carers said there was less communication with the service. Some families’ carers said that the meals were unhealthy.

One family member told us their relative could be challenging but they felt they were well cared for. Another relative said their relative was a “changed person” since going to the Willows and they were able to go home last Christmas. A family member spoke about enjoying regular meetings in the service gardens with their relative. Families and carers said the wards were clean.

One patient at Stewart House told us other patients made comments around their protected characteristics and staff had not care planned the needs of the patient.

The trust also collected feedback from patients in a variety of ways, including surveys, iPads, community forum meetings and the Friends and Family Test. The trust told us patients across mental health inpatient wards had commented positively about their experience of care. Patients said staff who cared for them were knowledgeable, professional and friendly.

Community health services for adults


Updated 30 April 2018

Our rating of this service improved. We rated it as good because:

  • We rated safe, effective, caring and responsive as good and well led as requires improvement
  • Patients were protected from avoidable harm and abuse, systems were in place to investigate incidents and concerns and staff received suitable training in safety systems. Risk assessments were completed and care plans implemented to keep patients safe and promote wellbeing. The service had plans in place to manage service disruption and major incidents.
  • The service used evidence based, best practice guidance throughout its policies and procedures and ways of working. Clinical audit was taking place and learning was shared across the service. Staff were suitably trained with the relevant knowledge and skills to carry out their work, had regular appraisals and had access to the information they needed to perform their duties. Multidisciplinary team work both internal and external to the service was effective and patients were supported to make informed decisions about their care.
  • Patients were supported, treated with dignity and respect and involved as partners in their care. They told us that staff were kind and caring.
  • Services and care were planned with the local population in mind and to address the individual needs of patients. Facilities had been adapted to improve access and systems were in place to support the most vulnerable. Patients knew how to make a complaint or raise a concern and complaints were taken seriously.
  • A new leadership structure had been introduced since the last inspection and had not yet fully embedded in the service. Leaders were motivated and developing their skills to address the current challenges to the service. Staff support systems were in place and there was a drive to engage with staff. Governance structures were in place and risks registers were reviewed regularly.


  • The service still had challenges in recruiting sufficient staff which meant that the service, in particular community nursing, was understaffed at times impacting on staff satisfaction and compromising patient care.
  • Staff did not always have time to attend clinical supervision sessions and patient information systems were inconsistently utilised and did not always enable effective working.
  • Patient outcomes were not routinely collected so the quality of the clinical care being delivered could not be measured or benchmarked.
  • There were long waiting times from initial referral to being seen in some clinics and services although these had improved in some areas since the last inspection.
  • The community nursing service could not measure its performance in relation to response times for unplanned care.
  • The leadership, governance and culture did not always support the delivery of high quality person centred care.
  • Staff satisfaction varied greatly across the service with some staff feeling devalued.

Community health services for children, young people and families


Updated 8 February 2017

We rated families, young people and children services as good because:

  • There were systems in place for reporting incidents and the service was able to demonstrate learning and sharing following incident investigations. However, staff told us they had little experience of incident reporting within the community children’s services.

  • Safeguarding was a high priority with regular safeguarding reviews within each area of speciality and established systems for supporting staff dealing with distressing situations.

  • Staff followed infection control practices and maintained equipment through regular servicing.

  • Patient records were electronic, up to date and available to the multidisciplinary team to enable an integrated approach to care and treatment.

  • Staff were trained appropriately within their speciality and new staff were supported to gain experience and skills.

  • Children and young people felt listened to in a non-judgmental way and told us they felt respected. We observed positive interactions between staff and children and the use of age appropriate language. The school nurses used technology to communicate with young people.

  • The service employed care navigators to help families and carers negotiate their journey through the various services provided.

  • There was an established five year strategy and vision for the families, young people and children’s (FYPC) services and staff innovation was encouraged and supported. Staff expressed pride in their ability to work as a team and managers told us they were proud of achievements. Staff were included in service developments and involved in ‘listening into action’ projects for service improvement.


  • There was a lack of reporting and monitoring of informal complaints, meaning the service was unable to monitor and recognise themes of concern with the children’s service.

  • The service is not appropriately commissioned to provide sufficient school nurses to meet the standard service recommendations of one nurse per secondary school and its associated primary schools.

  • The medical and senior leadership provision within the looked after children service did not meet the professional requirements outlined in the intercollegiate document for this provision.

Community health inpatient services

Requires improvement

Updated 8 February 2017

We rated community health inpatient services as requires improvement because:

  • Despite considerable effort with recruiting new members of staff, staffing was the top concern for all senior nurses and there was still a significant reliance on agency staff to fill shifts which could not be covered internally. Senior nurses mitigated risk where they could which included switching an agency staff member with a trust member of staff if two agency staff worked together. However, we saw evidence this was not always achieved.

  • Staff were open about their poor understanding around the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards. Our observations during inspection confirmed that staff knowledge and practical application of their knowledge was inconsistent despite training on their electronic learning systems.

  • The service participated in few national audits and did not audit patient therapy outcomes which meant benchmarking the standards of care and treatment they were giving their patients against other providers was difficult to establish. The service did however, complete local audits and produced action plans for improvement in care.

  • All hospitals were running at a high bed occupancy level of above 85% which national data has linked to increased risk of bed shortages as well as an increase in healthcare associated infections.

  • The service had 175 delayed discharges between August 2015 and July 2016, which accounted for 43% of the trusts total delayed discharges. The most common reason for delayed discharges was due to family choices which were beyond the control of the trust. However, delay in paperwork completion was also responsible for a large proportion of delayed discharges.

  • Staff were unaware of any service specific strategic direction. This had previously been identified on the CQC inspection in March 2015.

  • Concerns about high bed occupancy, record keeping and delayed discharges were identified in the March 2015 inspection and had not been sufficiently addressed.


  • The electronic prescribing system which the trust had implemented supported the safe administration of medicines to patients, with staff reporting very few medication errors as a result of this.

  • The feedback from patients and relatives was mainly positive about the staff providing care for them. Comments included terminology such as ‘marvellous’, ‘wonderful’ and ‘excellent’. All patients told us staff respected their privacy and dignity.

  • The introduction of activities co-ordinators at Coalville Hospital had improved the patient’s experience on the ward and increased the activities that were conducted on a day to day basis.

  • Staff told us they enjoyed working at the trust and thought they all worked well as a team. We saw evidence of good team working during our inspection.

Community end of life care


Updated 8 February 2017

We rated end of life care services as good overall because:

  • The trust had worked collaboratively with local partners to develop an end of life care strategy for the region as a whole which had incorporated a health needs analysis.

  • Patients were protected from avoidable harm by sufficient staffing and safeguarding processes.

  • Staff recognised and responded to the changing needs of patients with anticipatory medications readily available and care needs assessed and reviewed appropriately.

  • Staff followed infection and prevention control practices and the community inpatient wards were visibly clean. Specialist equipment needed to provide care and treatment to patients in their home was appropriate and fit for purpose so patients were safe.

  • Staff demonstrated commitment to delivering high quality end of life care for their patients. There was a strong, person-centred culture. Staff treated patients with compassion, dignity and respect. Patients and their relatives felt involved in the care provided. Patients’ social, emotional and religious needs were met and relatives valued the emotional support they received.

  • Services were planned and delivered in a way that met the current and changing needs of the local population. The needs and preferences of patients and their relatives were central to the planning and delivery of care with most people achieving their preferred place of care. Care and treatment was planned and delivered in line with current evidence-based guidance, standards, best practice and legislation.

  • We saw evidence of multidisciplinary working, with staff, teams and services at this trust and external organisations working in partnership to deliver effective care and treatment.

  • There was strong local leadership on the community inpatient wards and in the community. Staff told us they felt supported by their line managers, ward managers and matrons.


  • There were inconsistencies in the quality of completion for do not attempt cardiopulmonary resuscitation (DNACPR) forms, in the quality of admission paperwork within medical records and in the use of the ‘Last Days of Life’ care plans. This had been raised as a concern in the March 2015 inspection and had not been sufficiently addressed.

  • There was an unstructured, non-mandatory approach to formal end of life training for community hospital staff.

  • Concerns were raised regarding the fast-track process and appropriateness of admissions to hospital by the out of hours GP service.

  • We did not have assurance service leads had good oversight of the risks relating to this service as staff were not always recording incidents, the service was unable to identify incidents specific to patients at the end of life and concerns relating to the out of hours GP service were not formally recorded.

Child and adolescent mental health wards


Updated 8 February 2017

We rated child and adolescent mental health wards as good because:

  • The ward had clear lines of sight in the main areas of the ward. In the dormitories, observation mirrors were situated so that staff could observe patients without having to disturb them.

  • The ward had an up to date ligature risk audit, staff mitigated the risks on the ward by observing patients. Staff mitigated the risks posed in the garden area by accompanying patients when they wanted to access the garden.

  • The ward had sufficient staff to provide care and treatment to patients.

  • Staff followed the trust policy on seclusion. Data provided by the trust showed there were four episodes of seclusion from February 2016 to July 2016. Staff monitored the ongoing condition of any secluded patient.

  • 100% of staff were trained in how to safeguard children from harm. Staff informed us there was a safeguarding lead to refer to when guidance was needed.

  • Staff updated risk assessments and individualised care plans regularly. Patients had their own copies of care plans and were involved in their care plan reviews.

  • A psychologist led weekly reflective practice sessions to help staff think about the best way of helping the patient on the ward.

  • Patients’ reported staff treated them with dignity and respect. Staff interacted with the patients’ in a positive way and was respectful to them.

  • Patients knew how to formally complain and could attend daily community meetings where they could raise any issues of concern.

  • Staff said morale was good and they felt supported by their managers.


  • The service used a computer record system that differed from the rest of the trust. Other professionals within the trust could not access this system. Staff said the system was difficult to use and this had affected the information recorded in patient’s notes.

  • Staff and carers said that when a patient was discharged, it was difficult to allocate them to a community CAMHS worker.

  • Patients said they got bored at the weekends, as there were fewer activities on offer.

Community mental health services with learning disabilities or autism


Updated 8 February 2017

We rated community based services for people with learning disabilities or autism as good because:

  • Staff worked well as a team and morale was high. Multi-disciplinary team meetings took place on a regular basis. 89% of staff had attended their mandatory training; 92% of appropriate staff had received training in safeguarding adults and 90% of staff had completed safeguarding children training.

  • There were good systems for lone-working which included a code word that staff used when they required assistance. Staff said this made them feel safe whilst visiting patients at home or whilst undertaking activities with patients in the community.

  • Staff undertook comprehensive assessments and developed high quality care plans. The assessment and resulting care plans were personalised, holistic and recovery focussed. Staff made individualised risk assessments which were regularly updated and followed best clinical practice. Staff managed their caseloads effectively; they discussed their caseloads during multi-disciplinary team meetings as well as in supervision. The teams did not have waiting lists for care coordinators at the time of inspection.

  • Staff treated patients with kindness, dignity, and respect. Staff allowed patients time to respond to questions and did not try to hurry them. We spoke with six patients who all told us that the staff were very kind and looked after them well.

  • The teams were able to respond quickly when patients or carers telephoned with problems. We spoke with carers; they all stated that staff responded well when they contacted the service.

  • Staff were given opportunities to expand their knowledge and develop their roles. They could undertake both internal and external training and were able to give feedback on service development.


  • Three out of 18 staff interviewed said that supervision was irregular.

  • All the team leaders we interviewed said there were internal waiting lists for patients who had been initially assessed to access profession specific treatments.

  • The service had not met the six week target for initial assessment, on average patients were seen six days over the target date.

  • Access to rooms to undertake activities in the community for people with autism had been reduced.

  • Patients were not always involved in the planning of their care. Five out of 25 care records showed that patient involvement had not been recorded.

  • The walls in patient areas at the child and adolescent mental health team were visibly dirty in places and rooms were sparsely furnished.

Mental health crisis services and health-based places of safety

Requires improvement

Updated 30 April 2018

Our rating of this service stayed the same. We rated it as requires improvement because:

  • We rated responsive and well led as requires improvement, and safe, effective and caring as good.
  • Interview rooms were unsafe. They did not have alarms or vision panels in the door. They contained items which could pose a danger to staff and patients.
  • Staffing levels were below the expected level. The vacancy rate for the service was 12.9% and for band 5 and 6 nurses was 18.9%.
  • The quality of the data produced was poor and staff needed to correct the data when reports were produced.
  • The service was not meeting its performance targets.


  • The trust had addressed the issues previously identified with the health based place of safety.
  • Care plans were up to date and holistic.
  • There was effective communication between the service and other healthcare professionals.
  • Staff received regular managerial and group supervision.

Forensic inpatient or secure wards


Updated 8 February 2017

We rated the forensic inpatient/secure services as good because:

  • Phoenix ward had clear lines of sight for staff to observe patients. However, Griffin did not. Managers had plans in place to address this issue. However, no time frame was set for the work to be completed. Managers completed ligature audits which highlighted what mitigation was in place to reduce the risk for patients.

  • Staff completed comprehensive assessments which included physical health checks and the majority of patients had completed risk assessments. Staff ensured that these were updated regularly.

  • Staff used the mental health clustering tool, which included Health of the Nation Outcome Scales (HoNOS) to assess and record severity and outcomes for all patients. Advanced Directives had been introduced to enable patients to make decisions now about their long term care.

  • Managers had a recruitment plan in place to increase the number of substantive staff for the service. Managers ensured they used regular bank staff to achieve the required safer staffing levels and to promote continuity of care of patients. 83% of staff received mandatory training. Managers ensured they monitored their staff’s compliance with mandatory training using a tracker system. 78% of staff had completed their annual appraisal. Managers ensured they monitored the reporting and recording of incidents and complaints. They provided feedback to staff via monthly ward meetings, MDT meetings supervision and handovers.

  • Patients gave positive feedback regarding the care they received. Patients were able to access hot and cold drinks any time during the day. Patients could approach staff at night to request them. Staff interacted with patients in a caring and respectful manner. Staff we spoke with demonstrated their dedication to providing high quality patient care.

  • Wards had well equipped clinic rooms with appropriate equipment which staff regularly checked.

  • The average bed occupancy was low. The service did not have any out of area placements, readmissions or delayed discharges. Staff worked with both internal and external agencies to coordinate care and discharge plans.

  • The trust had a range of information displayed on the ward and the hospital site relating to activities, treatment, safeguarding, patients’ rights and complaint information.


  • The service had seven vacancies for qualified nurses and three for non-registered nurses.

  • There was a blanket restriction. On Phoenix ward patients were not allowed access to the garden. However, this was a temporary restriction due to the building works and patient safety.

  • Clinical supervision rates were low. 42% of staff on Phoenix ward and 27% Griffin ward had received clinical supervision. Managers did not ensure that the staff were receiving regular clinical supervision and had not met the trust target compliance rate of 85%. Staff morale on Griffin ward was low due to the announcement of the ward’s closure upon the completion of works on Phoenix ward.

  • Staff explained to patients their rights under the Mental Health Act on admission and routinely thereafter, although we saw this was not always documented in the patients’ care notes.

  • Clinic rooms were overstocked with medications. Nursing staff did not have a stock list to randomly check medication which meant they could not reconciliation check.

  • The phones on each ward were in communal areas; the phone on Griffin ward had not been moved since the last inspection, although it had a privacy hood installed. There was a mobile phone in the ward office that patients could use for private calls, for example to a solicitor.

  • Patient views on the quality of the food were variable.

Wards for older people with mental health problems


Updated 8 February 2017

We rated wards for older people with mental health problems as good because:

  • The wards complied with the Department of Health 2015 guidelines on single sex accommodation.

  • Patients reported that they felt safe.

  • The use of restraint was low and staff used it as the last resort and if verbal de-escalation had not been successful.

  • Managers had a system in place for tracking and learning from safeguarding incidents and other reportable events.

  • Managers used a tool to identify and review staff numbers in accordance with need.

  • Staff completed detailed risk assessments for patients on admission and reviewed them regularly after incidents.

  • Staff were observed to be caring and responsive to patients.

  • Staff monitored patients’ physical health regularly from the point of admission.

  • Care records were up to date and holistic.

  • There was a range of treatment and activity delivered by skilled and experienced staff.

  • Patients and carers knew how to complain.

  • Staff described managers as supportive and approachable.

  • Staffs were dedicated, passionate and patient focused.


  • Managers did not ensure that staff completed Mental Capacity assessments in line with the Act.

  • On Kirby ward there was no evidence of Section 132 rights read on detention in 54% of records reviewed.

  • There was minimal evidence of patient involvement in care plans.

  • Between August 2015 and July 2016, there were 60 delayed discharges across the service.

  • There were no dedicated visiting rooms.

  • At times, there were insufficient qualified nurses on shift.

  • Clinical supervision was not taking place regularly across the service.

Acute wards for adults of working age and psychiatric intensive care units

Requires improvement

Updated 5 May 2022

We carried out this unannounced focused inspection because at our last inspection in 2021, we had concerns about the quality of services and issued enforcement action. At this inspection we assessed what work the Trust had undertaken, as a result of the enforcement action we issued. The Trust was required to make significant improvements in some key areas.

We did not inspect all key questions in all domains because this inspection was undertaken specifically to assess progress the Trust had made to meet legal requirements after the last inspection. We are monitoring the progress of improvements to other key lines of enquiry in other services following the inspection in 2021 and will re-inspect them as appropriate.

The action we told the Trust to take following the last inspection were:

  • to improve ways in which patients could call for help in an emergency
  • to take action to eradicate shared sleeping arrangements (dormitories).
  • to improve ways in which patients’ privacy and dignity were protected.

We inspected some but not all key question in the domains of safe, effective, caring, responsive and well led in one service. The key questions inspected were in relation to the areas of concern in the enforcement action we took following the last inspection.

At this inspection, we visited the following service:

  • acute wards for adults of working age and psychiatric intensive care units.

We re-rated the ‘Safe’ and ‘Responsive’ key question only at this inspection. The ‘Safe’ key question rating improved from inadequate to requires improvement. The ‘Responsive’ key question rating improved from requires improvement to good. Other key questions not inspected at this inspection will be addressed at future inspections.

Effective, Caring and Well-led were not re-rated.

The overall rating of requires improvement for acute wards for adults of working age and psychiatric intensive care units remains the same.

The Trust overall rating of requires improvement remains the same.

The Trust have met all actions required in the enforcement action issued at the last inspection.

We found:

  • On Watermead and Thornton wards, all patients now had a way to summon help in an emergency. Across all wards at the Bradgate Mental Health Unit (BMHU), all patients had now been risk assessed for a wrist worn personal alarm, which could be used to summon help in an emergency. A paper-based risk assessment form was now in place for every patient which showed staff had considered the need for a wrist worn alarm. The form included the patient’s involvement in the decision. Where patients had declined an alarm, staff documented this decision. Patients who wore wrist alarms, knew how they worked.
  • Fixed alarms in toilets and bathrooms were now insitu.
  • The Trust had completed major environmental works to eliminate shared sleeping arrangements (dormitories), in the timeframe outlined in their action plan. One ward remained with shared sleeping accommodation (dormitories) at the time of our inspection. However, this ward (Aston) was relocating to a newly refurbished, single occupancy bedroom ward so that refurbishment could start. This meant, all wards at the Bradgate Mental Health Unit (BMHU) would be single occupancy.
  • Patients had sufficient space to store personal belongings. Every bedroom had a floor to ceiling wardrobe and a chest of drawers. Every patient had access to lockable storage and additional storage space in separate room on the ward.
  • Staff were aware of the importance to protect patients’ privacy and dignity. Every bedroom door now had a permanent sign which reminded staff to knock before entering.


  • Staff did not routinely upload paper-based risk assessments for patient wrist alarms into the patient’s electronic care record as per Trust policy.
  • Staff had not consistently completed care plans in the electronic patient record for those patients who wore wrist alarms.
  • Staff did not test the wrist worn alarms or fixed room alarms regularly on all wards and record the outcome as per Trust policy.

How we carried out the inspection

We carried out this inspection to follow up on enforcement action we issued at the last inspection in 2021. These concerns were in relation to some of the key questions of Safe, Effective, Caring, Responsive and Well led. Therefore, our report does not include all the information usually found in a comprehensive report. We have only re-rated the ‘Safe’ and ‘Responsive’ key questions for one service.

The rating of ‘Safe’ improved from inadequate to requires improvement. The rating of ‘Responsive’ improved from requires improvement to good. All other key questions were not re-rated.

The overall rating of requires improvement for this service remains the same.

The Trust overall rating of requires improvement remains the same.

During our inspection, our inspection team carried out the following activities across wards:

  • interviewed 11 staff including charge nurses, healthcare assistants and two senior managers
  • spoke with 14 patients
  • visited six wards of seven wards and reviewed the environment and bedroom spaces
  • reviewed governance systems and processes in place to deliver safe care and treatment
  • reviewed minutes of team meetings, MDT meetings and board papers and reviewed a range of policies, procedures and other documents relating to the running of the service
  • reviewed 35 care records, including risk assessments and care plans.

What people who use the service say

One patient told us how well balanced the system was to assess if patients needed a wrist band alarm. They told us the process was not discriminatory or had a hierarchy that singled out patients who needed an alarm. They told us they felt having an alarm was accepted by all. And made them feel safe. Another patient told us they had been risk assessed twice for a wrist band and had declined but understood the purpose of the wrist alarms. One patient on Aston ward said their visitor had not been given an alarm to wear. One patient told us they had agreed to have an alarm but could decide when they wore it; it depended on how they felt each day.

Some patients reported agency staff still did not knock on their bedroom doors.

Substance misuse services

Updated 10 July 2015

We do not give an overall rating for specialist services. However, we found:

  • The service was not safe. There were insufficient systems in place to monitor prescriptions. There were examples of people not being seen within service guidelines whilst receiving large doses of prescribed medication.
  • The service was not effective. While they made appropriate assessments and were responsive to changing needs, NICE guidelines were not used to ensure best practice and that multi-agency teams worked well together.
  • The service was not well led. There was a clear vision for the service which staff understood. However there were significant problems with key areas of governance in relation to the management of prescriptions.


  • The service was caring. Staff interacted with people in a positive way and were person centred in their approach.
  • The service was recovery focused and had developed pathways with other agencies to build on recovery capital for people who used the service. People felt they had benefited from the service and told us how caring staff were.
  • The service was responsive. The opening hours were flexible to accommodate the needs of the people who use services and there was protected time within the open access services to assess people who were referred to treatment.
  • The work in neighbourhoods reduced travel for people and reduced barriers for people to gain support.

Community-based mental health services for adults of working age

Requires improvement

Updated 30 April 2018

  • Staff treated patients with respect and maintained dignity.
  • Staff felt supported by their managers and received regular supervision and annual appraisals.
  • There was effective multidisciplinary working. Staff monitored those patients on the waiting list regarding risk levels.
  • Staff had been given lone worker safety devices to ensure their safety.