Leicestershire Partnership 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

At our last inspection we rated this key question requires improvement. At this inspection the rating has changed to good.

Good: The service had high demand and used bank and agency staff to cover consultant and nursing vacancies and meet safe staffing levels. Substantive staff were highly trained and experienced. The service had a proactive culture of learning from safety incidents. However, changes to medicine regimes were not always monitored or accurately documented in people’s care records. The care environments did not always safeguard people from harm. Care plans and risk assessments were not always current or detailed.

This service scored 63 (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 had a proactive and positive culture of safety, based on openness and honesty, in which concerns about safety were listened to, safety events were investigated and reported thoroughly, and lessons were learned to continually identify and embed good practices.

The adult community mental health service had a proactive safety culture. Staff at all levels told us about learning from safety incidents and could provide examples of changes that had been made in response to incidents. Most staff and managers told us that the trust focused on learning from safety events rather than blaming staff or teams when things went wrong. All staff received patient safety training to ensure that any incident that occurred was reported appropriately.

The trust had implemented the NHS Patient Safety Incident Response Framework (PSIRF). The Patient Safety Incident Response Policy stated the roles and responsibilities of all teams and individuals within the trust. Patient safety incident response flowcharts helped managers follow the appropriate course of action after an incident, including the documentation of action taken. Staff debriefs helped identify any immediate learning. The trust held weekly incident review learning meetings, in which relevant and specialist professionals reviewed any incidents that had been escalated for potential for investigation, and a decision would be made about the level of investigation or learning response required.

There were opportunities for staff to be kept informed of any changes or updates to practice and standards. For example, teams held face to face monthly business meetings which always started with a guest speaker. Some staff told us previous guest speakers had delivered presentations on topics such as depot medication, neurodivergence and research. During business meetings, feedback from people who used services was shared along with learning and recommendations from any incident reports. Staff were also given feedback from quality and safety and operational meetings and any audits that had been completed.

Learning from incidents was shared with all staff at incident review meetings and business meetings. It was also discussed at quality and safety meetings chaired by the deputy head of nursing, which helped to join all teams’ learning across the adult community mental health service. Trust-wide story boards were shared across teams when incidents led to wider learning. Staff told us about, and we saw, a story board about the need to have conversations with people who used services to remind them about DVLA’s rules and expectations regarding safe driving.

Staff and leaders told us examples of learning that had occurred from incidents. For example, someone who used services had tried to break into the assertive outreach team offices and the shutter controls were in the entrance foyer, outside the main building. After the incident, the shutter controls were moved so they were controlled from inside the building in case of emergency, which provided greater protection to staff.

The trust had a patient and family liaison officer who provided focused support for people who used services and their families following safety incidents.

Staff and managers understood their duty of candour responsibilities. Duty of candour is a statutory duty that requires providers to be open and transparent when safety incidents occur and apologise to those involved. The service’s incident reporting systems included prompts for staff to ensure that duty of candour was applied. Managers told us that the service strongly encouraged duty of candour to be applied in situations where there was no harm caused, which they said helped to create a culture in which nothing was kept “secret” from people who used services. We reviewed duty of candour records and saw evidence that staff in the service held conversations with people’s loved ones and followed up on any new information gained from talking to them to investigate the impact it may have had on people’s care. They also reported back to people on the findings of their investigations.

The trust had a suicide prevention plan. The plan aimed to reduce the suicide rate over the next 5 years, improve support for people who self-harmed and improve support for people who had been bereaved by suicide. The plan identified the issues specific to the areas covered by the adult community mental health service. Within the plan, training needs were identified alongside updates to existing policies.

The trust had not experienced any ‘Never Events’ in the 12 months prior to inspection. Never Events are defined as wholly preventable patient safety events.

The service generally established and maintained safe systems of care, in which safety was managed, monitored and assured.

Referrals to the adult community mental health service went through to the central access point team, who triaged them before sending them to the relevant team. Community mental health team (CMHT) referrals were considered either urgent or routine. The CMHT standard operating procedure stated their aim to respond to urgent referrals within 5 days, and routine referrals had a target response of 6 weeks for assessment. If a referral required a crisis response, the central access point team would arrange it.

The March 2025 Board Performance Report showed that in January 2025, 45.6% of referrals achieved the 6-week target. Trust data showed the average wait between referral and initial assessment from 1 April 2024 to 31 March 2025 was 56 days across all CMHTs. During that period, the average number of days between referral and initial assessment was 92 in the East Leicestershire CMHT, 71 days in South Leicestershire CMHT and 69 days in North West Leicestershire. West Leicestershire CMHT averaged 19 days between referral and initial assessment between 1 April 2024 and 31 March 2025. The data did not differentiate between urgent and routine referrals.

Between 1 April 2024 and 31 March 2025, the assertive outreach team average wait between referral and initial assessment was 20 days, against a target of 42 days. During the same period, the psychosis intervention and early recovery team (PIER) average wait between referral and initial assessment was 10 days, against a target of 14 days.

Waiting lists were managed through procedures set out in the service’s Access to Treatment Policy and standard operating procedures, which referenced the use of a patient tracking list process. The patient tracking list policy stated it provided a multidisciplinary approach to overseeing the management of waiting lists for people not yet allocated a named professional. We saw evidence of patient tracking list meetings and waiting list reviews that resulted in escalation of urgent cases. After people were assessed, they were put onto waiting lists to be allocated a care co-ordinator or lead professional. Policy stated that people were to be allocated based on clinical priority, followed by chronological order. After their initial assessment, the service was to inform people they would be contacted after 12 weeks for a review, at which point they would agree with staff about the frequency of contact and reviews they would like before they were allocated. The standard operating procedure provided guidance that contained prompts to support telephone reviews with people to assess their mental health, risks and needs.

Senior leaders acknowledged that people’s mental health could potentially deteriorate whilst waiting for treatment. The trust told us they had introduced mental health drop in cafes to provide additional support whilst people were waiting. People could contact the central access point and access support through the voluntary, community and social enterprise sector. There were escalation processes in place for individuals working in the cafes, central access point and voluntary, community and social enterprise sector if they had concerns about an individual.

The adult community mental health service had recently introduced a role that aimed to support people who were on waiting lists for psychological interventions. The mental health wellbeing practitioner role provided initial support which some staff told us helped to reduce people’s risk of their mental health deteriorating whilst awaiting treatment from a psychologist. The role also assisted in cases that other members of the multidisciplinary team had identified would benefit from such interventions.

The quality of recording across teams and within teams was inconsistent, we saw recording of a good quality, however other records were poorer. Staff at all levels told us they were aware of issues with poor quality and inconsistency in records. In the assertive outreach team, we saw an example of a care plan that was not in date, but staff told us it would have been recorded as being in date due to how care records were set up and audited. Staff told us that when a new document was created, the system recorded it as being an in-date document, whether or not it had any content. Senior leaders were also aware of record quality concerns and had a quality improvement plan in place.

It was evident through conversations with staff and observations of care records, that staff had knowledge of the people they cared for and understood their risks. However, we found instances where staff did not always capture what they were doing in practice in people’s care records, which meant the information was not easily accessible to others who might need access.

The adult community mental health service’s standard operating procedures stated everyone who used services would be allocated either a care co-ordinator if they were under the care programme approach (CPA) or a lead professional. CPA is a model of care that was nationally withdrawn when the Community Mental Health Framework was introduced. The trust told us that whilst it implemented the new framework, people in the adult community mental health service who were already being treated under CPA remained under that framework to provide continuity.

The adult community mental health service had processes to manage risks that people experienced across their care journeys. According to standard operating procedures, if anyone contacted the central access point team or team duty function due to a deterioration in their mental health, they were added to the next multidisciplinary meeting discussion so a plan could be created.

People were given information about services available to them whilst they waited, including voluntary sector and emergency services. From May 2024 to May 2025, there were 35 patient safety incidents whilst people were on waiting lists. Of those, 8 resulted in low level harm (minor, non-permanent) and the other 27 resulted in no harm.

Weekly multidisciplinary team meetings included agenda items that supported oversight of people’s care and treatment needs. Teams discussed topics such as waiting lists, people who were currently in inpatient services and complex cases. The CMHTs’ multidisciplinary team meetings were attended by staff from other specialist teams. This allowed staff to discuss people’s needs directly with other specialists so advice could be sought, and plans could be made for people’s care. For example, perinatal services and employment support services attended referral management meetings to ensure people’s needs and treatment plans were being considered holistically.

We reviewed minutes of multidisciplinary team meetings in which staff from other services attended and were noted as having provided information about their work. For example, staff from the assertive outreach team attended a CMHT multidisciplinary meeting and told staff about how they worked with people who were often difficult to engage in other services and teams. We observed substance misuse staff and employment support staff in a multidisciplinary team meeting held at one of the CMHTs.

Some staff told us they felt the multidisciplinary team meetings supported teams to work together in people’s best interests and ensured that any transitions between teams or services were properly managed. Some staff and managers told us that cases were discussed in different multidisciplinary team meetings as well as individual supervision meetings. They told us this meant staff had opportunities to get ideas or advice from other colleagues on how best to support people on their caseloads.

The teams within the adult community mental health service worked together to support people’s care pathways. For example, we were told about joint visits that took place between assertive outreach and CMHT staff to support someone’s transition from assertive outreach into a CMHT.

We observed some effective team and multidisciplinary meetings. An occupational therapy allocation meeting showed a high level of understanding of people’s needs and risks. One of the multidisciplinary meetings we observed was well attended by all disciplines, both within and outside the CMHT that hosted the meeting. Discussions were thorough and showed an effective team approach to support people’s care that included discussions about waiting lists, discharges, new assessments and risks.

Staff were able to refer people who used services to specialist services and teams, both within the trust and the community. Some staff told us they could support people with referrals to autism spectrum disorder (ASD) and attention deficit hyperactivity disorder (ADHD) services as well as specialist drug and alcohol misuse services.

The assertive outreach team offered staged support in which people could be ‘stepped up’ and ‘stepped down’ depending on the complexity of their needs. This ensured people received an appropriate level of staff support and intervention that met their changing needs. Staff told us they supported people’s safe transfers to CMHTs.

Managers told us they had received a quality improvement award for their work on improving ‘did not attend’ (DNA) processes in CMHTs. The CMHT standard operating procedure and the trust’s DNA policy explained that people would not be automatically discharged from the service if they did not attend an appointment. There were processes for staff to follow to assess risk and try to engage people in their care and treatment. In the assertive outreach team, people had individualised did not attend (DNA), cancellation or failed home visit plans as part of their care plan. Most staff in the assertive outreach team told us that due to the nature of people’s illnesses, vulnerabilities and risks, they had to be persistent about seeing people who might otherwise not engage. This helped staff ensure people were not discharged prematurely from their service, and that they would continue to work with people to improve their mental health.

The adult community mental health service worked with system partners to ensure oversight of people who used primary and secondary services. The service had local shared care agreement procedures for different medicines people could be prescribed. The procedures made it clear what the responsibilities were of different teams and individuals involved in a person’s care, including their GP, mental health service care team, carers and themselves.

The adult community mental health service had a Planned Care Clinical Reference Group, which comprised multi-professional input including patient and carer lived experience partners. The lived experience partners had experience of using or caring for someone who used mental health services. The reference group provided senior clinical leadership for complex clinical decision making and ethical challenges. It also provided leadership for the transformation programme.

Staff told us they liaised with inpatient teams and bed management staff when they were due to recall someone under the care of a Community Treatment Order (CTO) into hospital. They told us they also co-ordinated any other services needed for the CTO recall, such as ambulance services or police.

The trust was part of a multi-agency group that made sure the principles of Right Care, Right Person were followed. Right Care, Right Person is a national approach designed to ensure that people with health and/or care needs are responded to by the right person who has the right skills, training and experience to best meet their needs. The trust and local police force had an escalation process for staff to follow to make sure people experiencing a mental health crisis were responded to by the appropriate agency and team.

The adult community mental health service participated in multi-agency risk assessment structures that supported the safety of people who used services, carers and the public. They attended Multi-Agency Public Protection Arrangements (MAPPA) and Multi Agency Risk Assessment Conference (MARAC) meetings.

The adult community mental health service worked with other teams and organisations to share learning. Staff from the service attended several clinical network meetings to discuss challenges and share best practice with other providers, look at national best practice and research.

The service had a proactive approach to safeguarding. It worked with people to understand what being safe meant to them and worked with partners on the best way to achieve this.

The adult community mental health service had safeguarding processes which staff in all roles told us about. Staff were trained in safeguarding at a level relevant to their role.

Compliance across CMHTs, assertive outreach and PIER in May 2025 averaged 97.8% for safeguarding adults level 1, 96.4% for safeguarding adults level 2, 96.8% for safeguarding adults level 3, 98.3% for safeguarding children level 1, and 96.1% for safeguarding children level 2. Of the teams eligible to complete safeguarding children level 3 training, compliance averaged 98.8% in July 2025. The trust had only recently introduced safeguarding children level 3 training for the PIER team at the time of the inspection. At the time of the inspection, the PIER team had 53.6% compliance in safeguarding children level 3. The trust informed us that in July 2025, compliance rates had increased to 96.4% in the PIER team. Staff and senior leaders told us about the specific and increased safeguarding risks that existed for some of the people who used services.

Staff received mandatory training in the prevention of radicalisation of people who used services. In May 2025, compliance in completion of basic level training to prevent radicalisation averaged 99% across CMHTs, assertive outreach and PIER. The level 3 training compliance averaged 96.9% across teams.

Staff had access to the trust’s safeguarding team and there was a safeguarding duty line to support staff with any queries. The trust’s Safeguarding and Public Protection Policy and Procedures emphasised that safeguarding was the responsibility of all staff, whether permanent or temporary. It had escalation processes to follow for different safeguarding situations, to ensure the safety of people who used services, carers, staff and the public.

Staff told us, and we observed, that safeguarding was regularly discussed at meetings including during safeguarding supervision, which was held at least once every 3 months. We observed referral meetings, multidisciplinary meetings and team allocation meetings in which safeguarding was discussed. During the meetings, staff displayed a good understanding of the vulnerabilities of people who used services, and a proactive approach to raising safeguarding concerns. Some staff told us that an incident form was completed every time a safeguarding incident was identified, or the trust’s safeguarding team was contacted. They also recorded the situation on the person’s care record notes.

Some staff told us community matrons carried out quarterly safeguarding audits. The audits looked at every instance in which a member of staff from adult community mental health services contacted the safeguarding team. They looked at when it was reported to the safeguarding team, and whether staff followed the team’s advice. The audits also looked at whether people’s risk assessments and care plans were updated to reflect the new level of risk. Between 1 February and 31 April 2025, the assertive outreach team made 4 safeguarding referrals, PIER made 18 and CMHTs made 28.

The service worked with other agencies and partners to keep people safe. Senior leaders of the trust attended Leicestershire and Rutland Safeguarding Adults Board meetings. We observed a multi-agency safeguarding meeting for someone who used services. A consultant, community psychiatric nurse and a student nurse from one of the adult community mental health teams attended. The service’s staff showed professional curiosity and a good understanding of the person’s specific vulnerabilities, and they contributed important information to help support the safeguarding plan.

Learning from safeguarding was shared in a safeguarding newsletter all staff could access. Most staff told us they were kept informed of any action or progress in relation to safeguarding concerns they raised. However, some staff said they often had to chase the safeguarding team for updates.

The service tried to work with people to understand and manage risks so that care met their needs in a way that was safe and supportive, and enabled them to do the things that mattered to them. However, not all risk-related documentation was kept up to date in people’s care records.

The adult community mental health service still had an inconsistent approach to assessing and monitoring risk. Whilst progress notes were generally thorough and medical letters were comprehensive, some of the care records we saw lacked up to date and/or robust care plans, risk assessments, risk management plans, crisis plans and discharge plans. We reviewed 26 records in relation to risk assessments, of which 6 did not have up-to-date, comprehensive risk assessments. Of the 6 that were not comprehensive and/or in date, 2 risk assessments were very brief, 1 did not contain significant historic risks, 1 did not match the risks on the person’s care record alert, 1 did not match risks identified in the person’s assessment and 1 was out of date. Of the 26 care records reviewed, 21 had current care plans. The trust confirmed that the 5 records without care plans had been reviewed and updated immediately after our inspection.

Staff did not always follow standard operating procedure guidance in relation to how frequently risk assessments should be reviewed. The trust’s Clinical Risk Assessment and Management Policy highlighted situations when staff should review risk assessments with people who used services, such as when they became aware of new risks. However, we saw a care record of someone who had been discharged from hospital and into the care of one of the teams 8 weeks before our inspection and their risk assessment and care plan had not been updated since admission to the team, though records showed risk concerns had been raised. Some staff across teams told us that they did not always have the time to update care plans or risk assessments as they focused on seeing people who used services rather than writing about them.

The trust’s audit of people on Community Treatment Orders (CTO) showed that in December 2024, the PIER team uploaded 66.7% of CTO action plans onto care records, and 70% in January 2025.

The adult community mental health service had set up a care planning quality improvement programme to improve care planning, record keeping, communication with people and carers, and to ensure standardisation across teams. The quality improvement programme’s task and finish group had their first meeting in April 2025 to agree their scope and plan next steps. Identified actions did not have timeframes for completion, however the task and finish group recommended it would take 18 to 24 months to embed changes, and they requested a dedicated project manager to lead the programme. The trust told us a new safety plan template had been created and was being trialled initially within one of the CMHTs.

The service did not detect and control all potential risks in the care environment. Although equipment, facilities and technology supported the delivery of safe care, effective procedures were not always in place to ensure people’s safety.

During inspection, we found that the reception and toilet area of the North West Leicestershire CMHT was shared with the child and adolescent mental health services (CAMHS), which was a safeguarding, privacy and dignity concern. We raised this on inspection and the trust rectified this immediately. The trust confirmed there had been no incidents in relation to this in the 24 months prior to our inspection.

We found that at the East Leicestershire CMHT, the building and office were not secure as staff routinely kept the office door unlocked throughout the day. We raised this on inspection and the trust rectified this immediately.

The adult community mental health service teams were generally based in safe environments that were regularly risk assessed and met the needs of staff and people who used services. Staff could access relevant safety and security information either on their computers, or in folders we saw in offices. All locations had environmental risk assessments, and all clinic rooms now had ligature risk assessments and control measures in place to reduce the risk of harm to people who used services. Staff had personal emergency alarms that could be activated if urgent assistance was needed. There were risk assessments that covered when staff were not based in their main office and staff had lone worker devices. There were systems in place to ensure staff locations were known when they went on visits.

However, not all staff used their lone worker devices in line with trust policy. Staff and managers told us this was a particular problem in the PIER team. The PIER team’s supervision meeting templates included discussion about the use of lone worker devices, which managers told us had been added to help encourage their use. One of our inspection team accompanied a PIER team home visit to someone who had recently been referred to the service. The staff member was not observed using a lone worker device or carrying out any safety calls. The trust later informed us the staff member’s lone worker device stopped working during the visit.

At the North West Leicestershire CMHT, staff alarms did not work in some parts of the building. Some staff told us they had raised concerns about this previously. We tested the alarm and found that not all areas of the building were covered by the alarm sensors. However, once in an area with a sensor, the alarm sounded and the response from staff onsite was fast, though some staff later told us they were not aware the alarm had been set off as they had not heard it. We raised this on inspection and the trust carried out a health and safety assessment of the alarm system a few days after the inspection.

East Leicestershire CMHT had limited clinic room space as they shared the building with Melton Mowbray Hospital and its services. Some staff and managers told us this sometimes limited the team’s capacity to see people onsite. They were able to book external venues to host groups and provide space for staff meetings and training.

Fire safety measures were in place in all team bases. Fire extinguishers were in date and evacuation procedures were displayed in prominent locations. First aid boxes were maintained and in date.

The service’s buildings were all clean and well maintained, with appropriate furnishings. All posters on display were in good condition. Clinic rooms contained necessary equipment for staff to provide care and treatment.

The North West Leicestershire CMHT building had just undergone a full refurbishment which included new flooring throughout. Most staff and a person who used services told us this had affected the sound quality in the clinic rooms resulting in echoes which was distracting. Staff told us that soundproofing options were being considered.

Staff-only areas were accessible by fobs or key codes.

Cleaning cupboards were securely locked and had signage to show they followed control of substances hazardous to health (COSHH) regulations.

The service had some shortfalls in its substantive medic and nursing posts. However, vacancy rates had decreased in the months before our inspection, and the service used bank and agency staff to ensure safe staffing levels were met.

Staffing challenges remained across the adult community mental health service. In some teams there were high levels of sickness and/or vacancies. This led to high levels of agency, bank and locum staff usage, which some staff told us they felt affected continuity of care for people who used services. However, the trust had an ongoing recruitment strategy.

In April 2025, some of the teams in the community mental health service had high vacancy levels compared with budgeted establishment numbers (the number of staff the service had calculated it needed and had budgeted for) in the following:

• Assertive outreach had nursing vacancies of 5.82 full time equivalent (FTE), equivalent to 22% of the budgeted establishment numbers,
• City East had nursing vacancies of 2 FTE, equivalent to 14% of the budgeted establishment numbers,
• PIER administrative and clerical vacancies were for 4.37 FTE, equivalent to 72% of the budgeted establishment numbers,
• PIER had additional professional vacancies were of 0.7 FTE, equivalent to 32% of the budgeted establishment numbers,
• South Leicestershire had nursing vacancies of 3.65 FTE, equivalent to 26% of the budgeted establishment numbers,
• City West had nursing vacancies of 5.8 FTE, equivalent to 45% of the budgeted establishment numbers.

There were insufficient substantive consultants in post in CMHTs. Some staff and senior leaders told us that combined with an increase in referrals, this contributed to increased delays in outpatient assessments and appointments and meant people sometimes did not get to see the same doctor. In North West Leicestershire, some staff told us that the booking of outpatient appointments was 7 to 8 months behind schedule. Some staff and senior leaders told us there was instability within teams due to frequent changes in locum staff. The trust informed us the lack of substantive consultants was not the cause of delays people experienced in receiving treatment and that they were instead the result of both increased demand on the service and the need for transformation. We saw evidence that referrals to CMHTs and outpatients had increased from 354 in April 2024 to 512 in April 2025.

However, locum consultant usage had decreased between May 2024 and May 2025, from 13.3FTE to 8.1FTE and the average time locum consultants had worked in teams was over 2 years. Consultant vacancies were as follows:

• East Leicestershire had consultant vacancies of 1FTE, equivalent to 50% of the budgeted establishment numbers. However, the vacancy was covered by a locum who had held the position for 5 months at the time of our inspection. The team was supported by a 0.5FTE speciality doctor in post,

• North West Leicestershire, which had consultant vacancies of 1FTE, equivalent to 50% of the budgeted establishment numbers. The vacancy was supported by 2 locum medics working in the team, one of whom started in the trust in 2019. The CMHT also had 1 speciality doctor and 1GP trainee working in the team,

• South Leicestershire, which had consultant vacancies of 1.55FTE, equivalent to 55% of the budgeted establishment numbers. The team was supported by 3 trainee doctors who undertook 2-3 clinics per week under consultant supervision,

• City West, which had consultant vacancies of 3FTE, equivalent to 75% of the budgeted establishment numbers. However, the team was supported by senior grade doctors, speciality trainees and a speciality doctor, which took them above medic establishment numbers for the team.

In response to the shortage of substantive consultants, the service employed locum and agency consultants to take the total number of consultants working in the service to 5.4FTE above budgeted establishment numbers to help support the service with clinical care and caseload management. CMHTs were supported by senior grade doctors, speciality trainees, speciality doctors and trainee GPs working in the teams. Senior leaders told us about initiatives the trust had in place to try to resolve their high consultant vacancy rate and establish substantive consultants in post. For example, they carried out international recruitment and had appointed 6 international medical graduates. One of the trainees was appointed an acting consultant role in one of the CMHTs in April 2025. The trust had supported 2 acting consultants from within the adult community mental health service to undertake Approved Clinician training.

Some teams had high rates of sickness, which meant they had higher agency and bank staff usage. Some teams had higher sickness rates than the trust’s average rate of sickness, which was 5.45% from April 2024 to March 2025. Some staff told us that due to staff sickness, people who used services experienced changes in staff at times, and potentially had their appointments cancelled. Some staff also told us that staff sickness had affected staff wellbeing and morale through increased workloads and risk of burnout. To mitigate this, the trust had several wellbeing initiatives in place that internal auditors confirmed aligned with the NHS Health and Wellbeing Framework. The NHS Health and Wellbeing Framework is an organisational tool which helps healthcare providers support staff health and wellbeing.

The trust used bank, agency and locum staff to cover vacancies and staff absence and ensure establishment numbers were met or exceeded. Across February, March and April 2025, 403 medical (doctor) shifts across teams were covered by agency staff, 122 administrative shifts (predominantly in the PIER team) were covered by bank staff, and 678 nursing shifts across teams were covered by both agency and bank staff. The trust told us that on average, 80% of medical shifts and 92% of nursing shifts were covered by substantive staff and that all medical locum consultants and most nursing staff were booked for long periods of time to reduce disruptions to continuity of care. They told us all locum consultants were supported by the appropriate level of trainee medics, who provided additional medic support to the adult community mental health service.

The trust’s Mandatory and Role Essential Training Policy set out expectations for the mandatory training of all staff and volunteers, including agency staff. Training compliance was generally high across all teams. The trust had recently introduced paediatric resuscitation level 2 training for the PIER team, following a review of training needs. At the time of our inspection in May 2025, 9.1% of eligible staff had completed the paediatric resuscitation level 2 training. The trust informed us compliance had increased to 86.7% by July 2025.

Staff in the adult community mental health service received regular supervision in line with the trust’s Supervision Policy. Clinical, management and safeguarding supervision were held at least once every 3 months. Teams and individuals could choose to hold supervision meetings more frequently to meet staff’s needs. The service now had consistently high rates of supervision compliance, with management supervision at 97% and clinical supervision at 98% according to data from May 2025. Bank clerical and administration staff were required to have 3-monthly management supervision and bank clinical staff were required to have 3-monthly clinical supervision. Senior leaders told us supervision meetings included a focus on staff wellbeing and staff and managers were encouraged to use a wellbeing wheel to support discussions on managing wellbeing.

All new staff and volunteers had to attend the trust’s corporate induction and complete mandatory training upon joining the trust. Staff were given an employee toolkit to cover the first 3 months in their new role. Corporate induction was followed by local inductions specific to the role and team people joined. Agency and bank staff were expected to complete the mandatory training relevant to their role and received a local induction. Managers told us that in the case of community psychiatric nurses, this involved 4 weeks of shadowing initially before having their own caseload. During the shadowing they would not carry out assessments or carry out the duty function independently. Some staff told us they had positive experiences of induction and managers told us they aimed to make sure new staff were looked after to settle into their roles.

The service assessed and managed the risk of infection. Staff controlled the risk of infection spreading.

The adult community mental health service’s buildings were clean and well maintained. All staff were required to complete infection prevention and control (IPC) training at a level suitable to their job role. All teams had at least 92.9% IPC training compliance, with most at 100% compliance.

The trust had an Infection Prevention and Control Assurance Framework Policy. Some staff told us about the regular audits that were carried out to monitor IPC compliance. For example, adherence to the Hand Hygiene Policy was audited monthly and adherence to the Personal Protective Equipment For Use in Healthcare Policy was audited every 6 months.

The trust had an infection control nurse who provided support to the service. Staff had access to personal protective equipment such as gloves. Hand washing facilities and anti-bacterial hand gel were available. Toilets were well stocked with soap and paper hand towels.

Staff at all levels told us about IPC processes in place. Their clothing and hair styles supported the prevention of infection.

The service’s business continuity plans for each team included the effect that scenarios such as loss of water, floods, or drainage issues would have on IPC. The plans instructed staff on how to maintain IPC compliance in such situations.

We observed care being delivered in medicines clinics. Staff followed infection prevention and control measures including hand washing, wearing gloves and cleaning surfaces. Gloves were disposed of in the correct waste bin following single use with people who used services, and hands were washed again. There were pedal bins in clinic rooms so waste could be disposed of hygienically. In one clinic, we observed staff clean surfaces after the third of 4 people had their depot injection, but not after any of the others.

The service had systems in place to support people’s safe use of medicines by providing them with information. People’s care plans were not always updated in a timely way when changes in treatment occurred.

The adult community mental health service had systems and processes in place to support people with their medicines, but we saw evidence that people’s care records were not always updated when changes were made. Across teams, we saw evidence of care plans that did not accurately detail people’s medicines or any changes to them. For example, we reviewed 3 care records in which care plans did not reflect changes to people’s medicines, including 1 person who was prescribed an antipsychotic, but the documents were not consistently up to date with medicines regimes, so it was unclear for staff to know what doses were being taken. In 2 other care records, staff noted the person was not engaging with their physical health checks. However, this was not reflected in the care plan, and there was no evidence that the risks associated with this had been assessed or discussed with the person.One care record showed no updates had been made to a person’s care plan although it had been documented in progress notes that they had informed their CPN in April 2025 that they were not tolerating their medicine and wanted to try a different one. The trust informed us that some people may have frequent changes to medication to ensure adequate symptom control. This may be managed and implemented by the GP rather than directly by CMHT. We saw evidence that the service’s electronic prescribing system captured all dosage and frequency changes, maintaining an up-to-date record of treatment. This meant when a person was then seen in clinic, the doctor or nurse could review their most up to date medication regime and adjust the care plan accordingly.

All medicines incidents were reported electronically and automatically forwarded to the head of pharmacy. The head of pharmacy then assessed and handled the incidents.Across CMHTs, PIER and assertive outreach teams, there were 30 medicines incidents recorded between 1 November 2024 and 30 April 2025 and were a mix of staff (37%), patient and external agency errors. Most medication incidents reported between 1 November 2024, and 30 April 2025 resulted in no harm, and none resulted in high levels of harm.

The adult community mental health service had dedicated clozapine clinics and olanzapine depot clinics. Clozapine is an antipsychotic requiring strict blood monitoring. Olanzapine is a long-acting antipsychotic injection with recognised health risks following administration. People receiving this medicine were continuously monitored in appropriate facilities in line with trust guidance.Each team had local processes to manage people who required their depot administration. In the PIER team, local handover processes had been improved following learning from a medicines incident.

The adult community mental health service had identified through its transformation programme that the service’s capacity issues affected optimal monitoring for some people on depot and clozapine medications. This was on the corporate risk register as a high-level risk. It was not clear when this was added to the risk register, however it was monitored quarterly, with the next review due at the end of May 2025. One of the documented controls to reduce risk to people taking clozapine was pharmacy oversight of all people on clozapine. Staff and leaders confirmed there was pharmacy oversight of all people on clozapine.

The adult community mental health service took a proactive approach to improving its medicines optimisation. For example, as part of a quality improvement initiative, the service carried out a baseline audit in December 2024 and January 2025, which showed improvements were required in the initial assessment and follow up monitoring of people started on antidepressants.

Staff checked whether people were experiencing any medicines related side effects. The electronic patient record system contained prompts for staff to follow to review potential side effects.

Clinic rooms where medicines were stored were clean, and most were temperature controlled. However, in East Leicestershire CMHT, some staff told us the room medicines were stored in sometimes went outside the recommended temperature range. They told us, and we saw, this had been added to the local risk register. It had last been reviewed in April 2025 and was due for review in June 2025. The local risk register included a risk for City East CMHT due to the intermittent connectivity at the building, which meant that sometimes temperature data was not uploaded immediately from the device in the building. However, the trust informed us this did not affect the device’s ability to alert staff if temperatures went outside the correct range. Medicines management audits were completed regularly, and action plans were put in place when issues were identified.

The adult community mental health service worked with county-wide area prescribing guidelines, which included shared care agreements for most mental health medicines. These agreements outlined responsibilities for physical health and cardiometabolic monitoring. Shared care enabled people to access their medicines closer to home while ensuring appropriate ongoing monitoring.

Each GP practice in the area had a linked mental health facilitator employed by the trust which supported collaborative working between CMHTs and the GPs. This helped ensure people with severe mental illness received core physical health checks in line with national guidance. We reviewed 55 care records, and in each of those it was clear whether physical health checks were the responsibility of people’s GPs or the adult community mental health service.

Most people who used services received physical health checks. The trust monitored the completion of physical health checks via a dashboard and consistently achieved high rates of compliance. Between January and April 2025, the service achieved an average of 88% compliance of physical health checks.

The service had procedures to carry out regular physical health checks for people who were on specific medications. The physical health checks helped staff assess whether medicines were causing any negative side effects for people, in which case they could make changes to them. We observed staff offering physical health checks to people who used services during care and treatment appointments.

The adult community mental health service had a physical health lead pharmacist who had oversight of the necessary blood tests that were required for people with a severe mental illness who were under the Care Programme Approach. Some staff in one team told us they had recently established a physical health clinic to support this.

Some staff told us both clinics worked closely with the CMHTs to ensure continuity of care. They told us that in cases where people’s physical health check or blood test results were outside the normal range, these were escalated to the psychiatrist and recorded in care records.

A lithium register was in place. Lithium is a medicine used to treat a number of mental health conditions and its use requires frequent blood monitoring. Staff told us the lithium register enabled the service to maintain oversight of people prescribed lithium to ensure it was safe and effective.

The adult community mental health service used the same electronic patient record systems as most GPs in the area. We observed, and staff told us, this allowed sharing and access of information of people’s care and treatment. At the time of the inspection, there was direct clinical pharmacy support to the City East CMHT through a full-time pharmacy technician and a pharmacist one day a week. All CMHTs were able to access pharmacy support through a dedicated mailbox to which they could send pharmacy related queries for response from someone suitably qualified. We saw evidence of use of the mailbox in which a CMHT received a thorough response regarding a particular medicine and potential side effects.

The trust told us that consultants used Patient Information Leaflets (PILs) within outpatient correspondence to ensure people received detailed information about their prescribed medications. The trust also subscribed to a nationally recognised medication information website, which provided extensive details on medications, side effects, and other useful patient resources. This information was accessible on the trust’s public website. The trust told us they would be adding a direct link to the medication information website within the outpatient letter template.

We saw evidence that people's medicines were regularly reviewed in multidisciplinary meetings.

Medicines information was available to people in different languages and in easy read formats.