Leicestershire Partnership NHS Trust

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• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

At our last inspection we rated this key question requires improvement. At this inspection the rating has remained requires improvement. We identified 2 breaches of the regulations in relation to waiting times and caseload management. The score of 1 for the ‘Equity in access’ quality statement limits the key question rating to requires improvement.

Requires improvement: This meant people’s needs were not always met in a timely manner. As in our previous inspection in 2017, the service still did not always make sure people could access timely care and treatment. Waiting times in some community mental health teams (CMHTs) were long. Caseload sizes were high in some teams, particularly CMHT outpatients. However, the service understood the needs of its diverse populations and was working to tackle health inequalities. Staff worked with people to identify and work towards achieving their future goals. Staff identified and removed barriers to people accessing equitable care and treatment. Staff made reasonable adjustments to support people to access services. Care was planned in a joined-up way so people could access support in their local areas.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service made sure people were at the centre of their care and treatment choices. They decided, in partnership with people, how to respond to any relevant changes in their needs.

Staff told us the adult community mental health service provided a needs-based service that enabled people to access care and treatment to meet their needs, regardless of diagnosis. Some staff told us that they considered how to ensure care was person-centred. For example, staff told us that one person who used services had mobility problems and was reliant on a volunteer driver to get to appointments. Therefore, they arranged their appointment for when the volunteer could support them.

Care was delivered in ways that met individuals’ preferences. For example, we observed an assessment in which the light was kept off because the person was sensitive to lights.

Staff demonstrated how they accommodated peoples' specific needs during interactions. For example, one autistic person was provided with detailed information in advance to help them prepare for an upcoming clinic appointment. Additionally, their system record included information about their communication preferences, ensuring all staff were aware and could support them appropriately.

The service had made some improvements to the quality of its care planning since the last inspection. We reviewed 26 care records, of which 21 had current care plans. Although not everyone had care plans in place, of the ones we did review we saw they were holistic and demonstrated the goals and achievements that mattered to people. The patient and carer voice were evident in care plans.

With consent, carers were involved in people’s care. This helped staff better understand people’s unique needs and situations.

The service understood the diverse health and care needs of people in their local communities. This helped in providing care that was joined-up, flexible and supported choice and continuity.

People were allocated to named professionals throughout their time under the care of the service. The teams worked closely with each other and other services, to help provide information and guidance that supported seamless care journeys.

The standard operating procedure stated people who were discharged from CMHTs were given co-produced support and guidance on how to stay well. Everyone was given a mental health and wellbeing workbook, and information about other services they could access. Staff were required to develop relapse plans with people and provide information about how they could access the service again if needed.

The adult community mental health service provided employment support for people through their individual placement and support service (IPS). IPS is a model of supported employment specifically tailored for people with serious mental illness that helps promote recovery through obtaining jobs that align with someone’s strengths and preferences.

The staffing design of the adult community mental health service enabled teams to be more responsive to people’s needs. For example, Community Treatment Orders (CTOs) could be overseen by the service’s non-medical responsible clinicians. This meant there were more staff available to respond when people under CTOs needed to be recalled to hospital if their health had deteriorated.

The service had nurse prescribers, which reduced the burden on consultants to prescribe medicines, carry out medicine reviews or make any changes as needed.

People’s needs for medicines could be responded to quickly. People who used services told us they were able to access emergency prescriptions through the service. Staff in the assertive outreach team told us they had recently been able to send an emergency prescription elsewhere in the country when the person who used services went on a spontaneous trip and ran out of medicine.

Some staff told us the service had signed up to an application that contained details of a variety of voluntary, community, social enterprise and faith services. We saw the application database included a range of different groups that supported people’s health, wellbeing and social needs. Staff told us they could refer people to these organisations if needed, or provide signposting information when referrals were not needed.

The service provided appropriate, accurate and up-to-date information in formats that were tailored to individual needs. However, some people said they would welcome more information about medication choices.

The adult community mental health service complied with the Accessible Information Standard. The Accessible Information Standard is NHS guidance on what NHS and social care services must do to make services accessible to people with a disability or sensory loss.

Waiting rooms contained informative posters and leaflets. This meant people had easy access to information about the service, their rights, treatments, advocacy, groups and services, and how to make a complaint.

When people were referred to a CMHT, they were given a ‘Welcome to the Community Mental Health Team’ information leaflet. We saw a copy of the leaflet, which contained contact details for the team (including out of hours) and explained what people could expect from the team, including what would happen after assessment, who they would be working with, and confidentiality. The leaflet contained information about other services people might find useful to support their health and wellbeing or in an emergency. The leaflet told people they could ask for help to understand the leaflet or to get it in a different language or format such as large print, Braille or audio.

Information could be provided in multiple formats and languages. Some staff told us they could easily use translation services or book interpreters. They told us they were able to get documents created in Braille if needed.

People who used services received a confirmation letter after initial appointments were made. We saw a copy of the letter, which provided information that people would need to know, or that might help them feel reassured, about their appointment. For example, the letter gave point of contact and explained what to do if they were running late for an appointment or were unable to attend. The letter gave details on the location of appointments including public transport options and details of assisted travel and criteria. Letters for virtual appointments contained information about how to log on to the appointment.

People who used the adult community mental health service were given information about the service. People were given a range of leaflets at appointments and in waiting rooms, including one that explained who would receive copies of their care plan or any correspondence about their care, and what their rights were in relation to this.

The service was working to improve the accessibility and availability of information to people who used services and carers so they could understand their care and treatment. For example, one of the lived experience partners worked with staff to co-produce a frequently asked questions document and letter about being discharged from the service, which the trust reported had been “well-received”.

The adult community mental health service supported carers to have the necessary information to help them. Most staff told us the service did not disclose details about care without consent, but it did provide support to carers so they could better understand diagnoses and treatments and how they might best support their loved one. Some staff told us about a recent addition to the electronic record system to support carers. A ‘carers tab’ had been added, which meant staff could record carers’ details, with consent, and then send them their own care packs and support pathway information.

Staff in the adult community mental health service attended local annual wellbeing roadshows. The wellbeing roadshows were held in conjunction with other providers and support services. Some staff told us that speaking to people in person at the roadshows gave them the opportunity to clearly explain the service and advise people or signpost to other services as needed.

The service made it easy for people to share feedback and ideas or raise complaints about their care, treatment and support. They involved them in decisions about their care and told them what had changed as a result of their feedback.

The adult community mental health service offered opportunities for people who used services and carers to provide feedback. We observed suggestions and comments boxes in waiting rooms, alongside “you said, we did” boards that explained what action the service had taken in response to people’s feedback.

People’s views and input were sought when the service made any significant changes. For example, North West Leicestershire CMHT’s building was refurbished in 2024/25 and artwork was co-designed by people who used services. After the refurbishment, the service sent out surveys asking for feedback on the changes and suggestions of what else needed doing. Most feedback was positive and mentioned how much fresher and cleaner it was, however, people reported that the acoustics of the rooms were bad. At the time of our inspection, the service was waiting for soundproofing panels to be fitted and staff told us they were unsure when this was due to happen. The trust later informed us that different flooring was now planned to improve the soundproofing of the rooms and that following the feedback on acoustics, group work had been moved online.

The adult community mental health service worked with people who used services and carers to shape their services. There was a co-production group for CMHTs, and one for those under the care of the assertive outreach or PIER teams. These were chaired by lived experience partners and supported work on various projects to improve people’s experiences of care and treatment. For example, the CMHT co-production group reviewed leaflets to improve the service’s communication with people who used services and carers.

All staff were encouraged to support timely resolution of any concerns people who used services or carers raised. Staff and managers told us that in the first instance, concerns were directed to team leaders to deal with any problems and prevent escalation to a complaint. They told us this enabled staff to respond quickly to issues as they arose. Staff would also direct people who used services and carers to the patient advice and liaison service as needed and there were posters in waiting rooms with contact details.

Complaints received by the adult community mental health service were investigated thoroughly and responded to. We saw evidence that complaint investigations identified any learning for individual staff and the service. Complaint responses included explanations of what had happened, and apologies were offered as appropriate. In some cases, people were offered the opportunity to meet and discuss the situation with relevant managers.

Between 1 May 2024 and 4 May 2025, the adult community mental health service received 71 complaints. Of those 71 complaints, 3 were upheld and 23 were partially upheld. Ten of the 71 complaints had not yet been closed. Staff and senior leaders told us they thought the biggest causes of complaint were related to the waiting times for outpatient appointments and the frequent changes of locum consultants in some teams. However, the data showed that only 1 out of the 71 complaints we reviewed related to waiting times and only 4 out of the 71 related to their consultant. The service’s complaint data showed that ‘patient care’ was the most common complaint topic, with 21 complaints. ‘Communication’ was the second most complained about issue, with 14 complaints. Charnwood CMHT had the highest number of complaints with 15. Of the 71 complaints received, none were referred to the Parliamentary and Health Service Ombudsman. The 71 complaints reflected 0.65% of people on the case load and 0.06% of the clinical contacts in the same period.

People we spoke to said they would feel able to raise a concern or complaint if they needed to.

Between 1 May 2024 and 1 April 2025, the adult community mental health service received 280 compliments. Sixty-one of those were compliments about the PIER team. The CMHT with the highest number of compliments of the 280 received by the service was Charnwood CMHT, which had 58 compliments.

The service did not make sure that everyone could access the care, support and treatment they needed in a timely manner from CMHTs.

Some of the CMHTs in the adult community mental health service had long waiting times for people to be seen. In the 12 months prior to inspection, 718 people had not been seen in 12 months and there were 2149 breaches of follow up appointments not being within their target time frame. The average wait for outpatients across all CMHTs was 133 days. In East Leicestershire CMHT, the average wait for outpatients was 205 days. Some staff told us that in North West Leicestershire CMHT, outpatient appointments were about 8 months behind schedule. This meant people were at risk of experiencing significant delays to accessing the treatment they needed.

Between April 2024 and March 2025, the average number of days between referral and treatment was high across most CMHTs for outpatients and psychology. The average wait for psychology across all CMHTs was 351 days. In East Leicestershire CMHT, the average wait for psychology was 599 days.

The trust had added long waiting times on to the trust’s risk register. The risk was overseen by various boards and committees to review the potential impact on people who used services. Caseload reviews were underway within the CMHTs with the aim to reduce waiting lists by discharging people who no longer required support from the adult community mental health service. Caseload reviews had started 7 years prior to inspection, with a new method having been recently implemented. Senior leaders told us about South Leicestershire CMHT’s caseload review which took place over 9 months and in which 40% of cases reviewed were identified for discharge.

PIER team and some CMHT caseloads were high. According to their standard operating procedure, nurses in the PIER team were supposed to have no more than 20 people on their caseload. The PIER team’s caseload data showed all staff had caseloads within maximum limits. Band 5 nurses held an average caseload of 15, which was the recommended number. Band 6 nurses held an average caseload of 19.04, which was higher than the recommended caseload of 15, but below the maximum limit of 20. Band 7 nurses held an average caseload of 10, which was the maximum limit and higher than the recommended caseload of 8.

The CMHT standard operating procedure did not specify caseload targets. However, some staff reported high caseload numbers in some of the teams. Most staff and senior leaders told us outpatient caseloads for medics were high. North West Leicestershire CMHT consultants had individual caseloads of 384 and 553. An East Leicestershire CMHT consultant had a caseload of 547. Charnwood CMHT consultants had caseloads of 292, 298 and 324. City East CMHT consultants had caseloads of 491, 565 and 583. City West CMHT consultants had caseloads of 352, 351, 449 and 382. Although the CMHT nursing caseload averaged 10-16 across teams, there were some nursing staff with high caseloads such as a member of staff in City East who had a caseload of 64 people. The trust told us that some caseload numbers included people who were not receiving regular nursing interventions, for example those who only attended depot clinics. However, senior leaders told us they recognised the high caseload numbers created a barrier to care and treatment for some people.

At the time of our inspection, the trust was in the process of establishing a Waiting List Transformation Steering Group to address several services across the trust that operated waiting lists, including the adult community mental health service. The group had monthly activity and reporting plans through to December 2025, at which point the waiting list management programme would be reviewed and recommendations made.

Although waiting lists affected people’s access to care and treatment, staff identified and tried to remove barriers to people’s access to care where possible. For example, in one CMHT, they did not have any on site depot clinics. Managers told us this was because the area experienced high levels of deprivation, meaning many people did not have vehicles and public transport was poor. Therefore, clinics were held in locations that were more easily accessible for people who were dependent on public transport. Staff were able to book volunteer transport for people who needed it. Alternatively, depot medicines could be administered at a person’s home. Some staff told us they tended to deliver care in the community, such as carrying out ECGs and blood tests, as this helped remove barriers for people.

People who needed reasonable adjustments had a reasonable adjustment digital flag on their care record. This helped staff view details of reasonable adjustments and ensure these were in place for people when accessing care and treatment.

The adult community mental health service’s buildings and facilities were accessible to people with a range of mobility needs. Each location we visited had accessible toilets and waiting rooms had a range of chairs available to meet different mobility requirements.

A deep dive was being carried out to look at high ‘did not attend’ rates. Managers and senior leaders had a good understanding of the barriers some people may face to engaging with CMHTs. For example, Charnwood CMHT had a high student population, so the team worked with the local universities to support people. Staff recognised that in City East CMHT, there were many people who were from cultures in which families tended to look after people who were unwell. We saw evidence of work planned to address some of the inequalities with the South Asian population to help identify and reduce barriers to people accessing care.

The service actively sought out and listened to information about people who were most likely to experience inequality in experience or outcomes. They tailored care, support and treatment in response to this to meet people’s differing needs.

Staff in the adult community mental health service were mindful of providing an inclusive service that protected people’s human rights. Staff received training in equality, diversity and human rights and across teams the compliance rate averaged 99%.

Some staff told us examples of ways in which the adult community mental health service supported people to have equitable experiences and outcomes. For example, some staff told us they took people’s neurodivergent conditions into consideration when planning appointments, such as which room it would be in. One person who used services told us staff always considered their needs in relation to their neurodivergence and mental health diagnosis.

In North West Leicestershire CMHT, staff and managers told us about their building refurbishment which was nearly complete. One of the rooms had been allocated as a new sensory room for people who found the main waiting area did not suit their needs. Managers told us work on the sensory room was due to begin shortly after the inspection, though details of this were not recorded within the estates plans we saw.

Staff in different teams across the adult community mental health service told us about the diverse needs of their populations. They understood how this could impact people’s experience of care and treatment. For example, staff told us that some people did not have access to the internet, and why this meant that in-person appointments were preferable for many people.

The trust had implemented the patient and carer race equality framework (PCREF). The mandatory framework supports NHS trusts in their efforts to become truly anti-racist. The trust had involved Black heritage community organisations with its PCREF development. A PCREF Advisory and Design Group comprising staff, people who used services, and carers from racialised and marginalised communities, along with system and voluntary, community and social enterprise organisations. The group oversaw the implementation of PCREF.

The trust had commissioned the African Heritage Alliance to work with them to co-produce, test and design community activities to increase awareness of mental health and wellbeing. They would be creating a framework for working and co-producing with racialised and marginalised communities, to help tackle health inequalities.

The adult community mental health service identified and minimised barriers to equitable care, support and treatment. Staff had recognised a high number of suicides amongst certain populations. They sought to address this by going out to provide additional support in places where those populations were. For example, some staff told us they held outreach events at local truck stops after recognising the high rates of suicide and depression amongst lorry drivers.

Most staff and senior leaders told us reducing health inequalities was one of the main aims of the integrated neighbourhood transformation. Managers and senior leaders told us they were in the process of mapping the needs and demographics of their different patient populations.

As part of their focus on reducing inequalities, the adult community mental health service had undertaken work on specific demographic groups throughout 2024/25 and had plans to continue this work throughout the next year. Vulnerable communities had been identified so work could be done to increase access to support and support improvements in wellbeing for those people. For example, engagement activities with members of the farming community had taken place between 1 April 2024 and 31 March 2025. During the same period, the service provided increased access to mental health and wellbeing support to foreign nationals temporarily housed in nearby army barracks. Staff told us that a men’s mental health support group was being set up in response to the identified need for men in the community to have more targeted support, though they could not confirm when this would happen.

Staff were supported to learn different languages to support people who used services. In one of the CMHTs, we were told that a staff member was being supported to train in British Sign Language.

Staff told us about how they tried to reduce health inequalities by making sure they provided care in a way that best suited individuals. For example, electrocardiogram and bloods were regularly done in the community rather than people going to CMHT sites.

The service worked with people to consider the most appropriate support for their future plans and goals. However, high outpatient caseloads in some CMHTs required review so people could be discharged appropriately.

The adult community mental health service worked with people to create recovery and goal-focused care plans. We observed initial assessments during which people were asked what their future hopes and plans were. This helped staff plan care and treatment that could help people achieve their goals.

Most staff told us that the way their caseloads were allocated to individual staff meant they were able to properly get to know people who used services. They told us this helped them get to know what mattered to that person and meant they could deliver care and treatment that helped them support that person to achieve their goals.

Some staff told us about efforts to ensure people did not feel ‘abandoned’ when they were discharged from the service. For example, we were told that the service had reviewed the language it used in relation to discharge. Patient participation groups had fed back that the word “discharge” could sometimes make people feel worried that all help and support was being removed. Therefore, they had changed the wording of discharge letters, so they mentioned “transition back to your GP” instead of being discharged from the service. The letters provided information about other help people could access in the community.

The adult community mental health service took a tailored approach to planning people’s discharge at an appropriate time in their treatment journey. The service’s discharge processes and standard operating procedures ensured people were fully involved in planning their discharge. We saw evidence the service carried out monthly audits to review whether people were involved in discharge planning from CMHTs. Between March and May 2025, audit data showed that of all discharges from CMHTs, an average of 93.2% of people were involved in planning their discharge. We reviewed 26 care records in relation to discharge plans and saw clear evidence of discharge planning in 5 of them. The service was able to explain why discharge planning was not present in the other records we reviewed. Some people whose records we reviewed required long term CMHT input, some people had significant history of not engaging with services and others were not yet at a stage in their recovery where discharge planning was considered appropriate or necessary.

The teams’ standard operating procedures stated that people who used services should be offered an advance statement of wishes at each review. This meant there was a record of what medical care they wanted to refuse if they lost capacity to make decisions about it in the future. This allowed staff to consider people’s preferences if they needed to make best interests decisions on someone’s behalf when they were very unwell and lacking capacity.

Caseload reviews were underway within the CMHTs. Caseload reviews had taken place from 2018 and following a successful pilot, a formalised approach to caseload reviews had been adopted in 2023 and then rolled out across CMHTs. Caseload reviews helped to ensure people were appropriately supported, including being discharged from the service. We saw evidence that in South Leicestershire CMHT, 446 cases were reviewed by senior clinicians and operational managers. Of those 446 cases, 179 were identified for discharge. For those who were not discharged, intervention plans were put in place to support locum consultants who were taking on responsibility for those people. Seven people were identified as requiring an urgent review. Some senior leaders told us of plans to continue caseload reviews to support the safe discharge of people whose mental health was stable back into primary care.