Leicestershire Partnership NHS Trust

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

At our last inspection we rated this key question good. At this inspection the rating has changed to requires improvement. We found 1 breach of the regulations in relation to governance. The score of 1 for the ‘Governance, management and sustainability’ quality statement limits the key question rating to requires improvement.

Requires improvement: This meant the service management and leadership was not always effective. Governance processes were not always effective at addressing issues. However, staff and senior leaders had a shared culture focused on improving outcomes for people who used services. The trust’s vision for services was communicated effectively so staff understood how they would be affected. Staff had opportunities to speak up and most felt able to do so. The service had effective partnership working in place with local providers and communities. Staff were encouraged to use quality improvement approaches to improve services. There were opportunities to be involved in research.

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 had a shared vision, strategy and culture. All staff and leaders sought to understand and meet the needs of people and their communities.

The adult community mental health service had a clear vision and strategy. It was in the process of implementing its integrated neighbourhood transformation. This was shared with staff at all levels, partner organisations and people who used services. All staff we spoke to told us they understood the strategy and supported the move towards greater collaboration between teams, services and organisations.

All staff and senior leaders we spoke to had a good understanding of the needs of their patient populations. Staff could explain how their role supported the trust’s vision to improve community mental health services and health outcomes for people who used services.

Some of the assertive outreach staff shared they were previously unsure of the team’s future. Most staff told us the trust had previously considered the removal of the assertive outreach team. We were told this had caused some staff to leave the team in the past due to the uncertainty. However, when we spoke to senior leaders, they said that the assertive outreach team’s future was never in question.

The trust held engagement events and workshops for staff to help staff understand the changes and have their chance to ask questions.

Senior leaders and managers attended transformation huddles. Some managers and senior leaders told us this provided opportunities to review how the transformation was progressing and anticipate the outcomes of any changes. Weekly meetings were held to discuss emergent issues.

The trust had introduced its 2025-2030 strategy as part of its Associate University Group with Northamptonshire Healthcare NHS Foundation Trust. The strategy was developed collaboratively, with staff across the trust, senior leadership, staff network groups, lived experience partners, patient voice forums, board members and key partner organisations and stakeholders. Strategy documents clearly identified the areas of focus and the ambitions for the trust for 2030

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support. Leaders embodied the culture and values of their workforce and organisation. They had the skills, knowledge, experience and credibility to lead effectively and did so with integrity, openness and honesty.

We spoke to senior leaders and managers with experience in the roles they were managing. This helped ensure they understood the potential impact of decisions they made.

We spoke with senior leaders and directors. They could explain how teams were working to provide high quality care. They showed a good understanding of the services they managed, their achievements and their challenges. Senior leaders spoke candidly, with openness about where they felt there was need for improvement.

Managers and senior leaders were visible in the service. Many of them were based in the same offices as their teams. Most staff told us they found managers and senior leaders approachable.

There were leadership development opportunities available to staff. Most staff told us about a range of personal and professional development opportunities they had access to. For example, support staff could train to become nurse associates. There were opportunities to train to become a non-medical prescriber. In one team, we met staff who had been supported to progress their careers to become an advanced nurse practitioner and a nurse consultant who was also a responsible clinician. Some other managers had been supported by the service and spoke positively about the opportunities they had been given.

Matrix leadership had been introduced across the adult community mental health service. Matrix leadership is an organisational structure in which staff report to more than one supervisor or leader. All managers spoke positively about how this enabled regular contact across all levels of the organisation and parts of the service and meant they could always access support. They told us there had been a series of organisational development sessions to develop the leadership of teams from the directorate management team to individual professional teams. They said this enabled staff to share their thoughts and have a voice while developing team structures.

Staff knew how to raise concerns and the trust provided opportunities for this.

Staff told us they knew how to raise concerns and most felt able to do so. The trust’s 2024 National Staff Survey showed 79.8% of staff across the trust stated they felt secure about raising concerns about unsafe clinical practice, which was a 1.8% increase from the previous year. Additionally, 65.5% of staff across the trust stated they felt confident the organisation would address their concern, which was a 1.7% increase from 2023. However, some staff from different teams told us they would feel uncomfortable raising any issues. Another member of staff told us they were dissatisfied with how a complaint they raised had been investigated. They said that although the situation had been resolved, they were upset at the handling of the situation. We told managers and leaders on site, who immediately arranged additional support for that staff member.

Quality and Safety Committee meetings included reports from the Freedom to Speak Up Guardians. The reports highlighted themes and trends from issues raised by staff through Freedom to Speak Up processes. Between 1 April 2024 and 31 March 2025, 169 concerns were raised through Freedom to Speak Up across the trust. The February 2025 report stated that the main themes across the trust from November to December 2024 were worker safety and wellbeing, alongside attitudes and behaviours not aligning to organisational leadership behaviours and trust values.

All staff could access the trust’s Freedom to Speak Up Guardians. A Freedom to Speak Up Guardian is someone who works alongside the trust’s senior leadership team to ensure staff are able to speak up effectively and are supported appropriately if they have concerns about patient care. The trust had 2 Freedom to Speak Up Guardians and 22 champions, 5 of whom worked in the adult community mental health service.

The trust had established Freedom to Speak Up processes in place. The trust had carried out an internal audit of its Freedom to Speak Up provision, policy and procedures in 2023. Its policy stated the different responsibilities for all levels of staff, managers and leaders to create an environment in which people could raise concerns without fear of reprisals. The policy signposted staff to external organisations they may wish to raise concerns with if they felt unable to raise concerns within the trust. The trust had obtained independent assurance from an internal audit on Freedom to Speak Up processes in place.

The Freedom to Speak Up Guardians took actions to support the trust’s aim to have an open culture of speaking up and listening to concerns. For example, the Freedom to Speak Up Guardians attended staff support groups, attended clinical staff inductions and provided bespoke training and development sessions to different staff groups such as international nurses and students.

The trust held a series of events during October Speak Up Month. In 2024, this included a programme of engagement events including drop-ins, an interactive workshop with the National Guardian, and a compassionate leadership conference which had the theme Speak Up, Listen Up as its focus. In line with these events, there was an increase in the number of issues raised through Freedom to Speak Up in October and November 2024.

The trust valued diversity in their workforce. They took a proactive approach towards creating an inclusive and fair culture by improving equality and equity for people who worked for them and responding to any disparities in staff experience.

The trust had several initiatives in place that aimed to increase equality and equity for staff. Staff support networks provided opportunities for staff to seek support and learn from each other. The staff networks contributed to network events that were open to the wider trust to educate and raise awareness about different religious, cultural and health related topics. Staff could attend support networks including:

• Armed Forces,
• Carers,
• MAPLE (Mental and Physical Life Experiences),
• Men’s Health,
• Neurodiversity,
• REACH (Race Equality and Cultural Heritage),
• Spectrum (LGBTQ+),
• Women’s.

The trust carried out equality monitoring of its staff. The trust reviewed its NHS Staff Survey 2023/2024 Workforce Race Equality Standard (WRES) and Workforce Disability Equality Standard (WDES) results and identified actions to improve equity for racialised and disabled staff. For example, the trust had plans for its equality, diversity and inclusion team to work with its quality improvement team to embed equality, diversity and inclusion in the trust’s quality improvement processes. The trust reviewed its staff data to understand if any sets of staff had poorer experiences in relation to characteristics such as their sex, religion or sexuality. WRES and WDES data are only available at trust-wide level.

Staff and managers told us there had recently been communication about an updated policy on reasonable adjustments. Staff support networks supported a task and finish group to deliver regular reasonable adjustment clinics for staff which helped individuals and managers take practical steps to implementing reasonable adjustments appropriate for their specific circumstances. Some staff told us examples of reasonable adjustments that could be put in place to support staff, such as standing desks.

Most staff and managers told us that the trust was supportive of offering flexible working arrangements to staff. The Flexible Working Policy and Procedure supported staff who wished to make flexible working requests and stated the stages and timeframes of the process.

The trust’s Together Against Racism initiative took a zero-tolerance approach to abuse and violence. Staff network chairs had supported the development of trust approaches to inclusive recruitment, career development and cultural competency. The Zero Tolerance Taskforce had representation from across the trust and had produced training and a six-step process to support staff. We observed the co-produced zero tolerance posters on site.

Staff in the adult community mental health team could apply to participate in reverse mentoring. This gave more junior members of staff the opportunity to mentor more senior staff and leaders, offering a different perspective on the workplace, its systems and processes.

The trust provided opportunities for staff to complete a range of training in addition to mandatory equality, diversity and human rights training. Training courses included Race Equality, Disability Equality, LGBT+ Equality, Sexual Harassment Awareness training and the Active Bystander Programme. The Active Bystander training supported staff to recognise and address any bullying, harassment or victimisation they witnessed.

Although the service had set out responsibilities, roles, systems of accountability and governance to manage and deliver good quality care, treatment and support, these were not always effective. They did not always proactively identify and address potential issues that impacted care and treatment.

The adult community mental health service regularly carried out a variety of audits to assess the quality of care it provided. However, some of the service’s governance processes did not always operate effectively. They did not always identify appropriate action to address risks.

Governance processes had not been effective in successfully addressing environmental safety issues, quality of care records, and waiting lists and caseload management. In our 2017 inspection, we told the trust it must make improvements relating to care plans, risk assessments, caseload sizes and environmental risks. We did not observe evidence that all areas had been sufficiently addressed.

The service’s caseload review work was noted during our last inspection in 2017. However, CMHT outpatient caseloads remained high in our 2025 inspection. Since the implementation of a new caseload review method in 2023, most CMHTs had not undergone caseload reviews. This meant there were possibly people on caseloads who no longer required care and treatment from CMHTs, as indicated by the discharge of 40% of people on the caseload in South Leicestershire CMHT as part of the team’s caseload review. There remained long waiting times in some CMHTs.

Staff and managers on site had not been aware of the safeguarding implications of the shared waiting area for children and young people and adults in the West Leicestershire CMHT building when we raised our concerns with them. Health and safety audits had not highlighted the need for a specific process to safeguard children and young people. Although the situation was rectified immediately upon us raising concerns, the trust had not previously considered such measures necessary in their risk assessments.

The adult community mental health service was responsive to all concerns raised on site during the inspection and provided assurance that all issues were fully assessed and resolved within a week. However, some of these issues, including staff security, had not been picked up on at service level although some staff told us they had raised these concerns within their teams previously.

Policies and procedures we reviewed were in date, with clear review and expiry dates. Policies and procedures were written in clear, accessible language and had process flowcharts where needed to provide additional clarity. There was a process in place to ensure policies and procedures were reviewed and signed off at the appropriate level.

Equipment and information technology supported staff to carry out their work. The information technology infrastructure, including the telephone system, worked well and helped to improve the quality of care. Staff told us they had everything they needed to do their jobs.

Effective information governance systems were in place. These helped protect the confidentiality of people who used services and their care records.

We saw evidence of some effective clinical audit systems that identified issues and led to improvements being made. For example, safeguarding audits had identified that some staff were correctly following the safeguarding team’s advice but not completing the necessary forms. As a result, community matrons now gave direct feedback about safeguarding in multidisciplinary meetings. Additional training was also provided to increase understanding about the safeguarding process.

All staff said they understood the hub and spoke model of working. They could explain the arrangements for working with other teams, services and organisations to support people’s care and treatment.

The adult community mental health service had plans for emergencies. We saw evidence of accessible business contingency plans that covered a range of potential issues. The plans provided instructions for senior leaders, managers and staff to follow to limit disruption to providing care and treatment in the case of adverse incidents.

We observed several meetings across teams. Each meeting had a clear framework of what was to be discussed and by whom. Teams’ business meetings provided opportunities for all staff to access essential information, such as learning from incidents and complaints.

We saw evidence that the adult community mental health service implemented recommendations made from reviews of deaths, incidents, complaints and safeguarding alerts. For example, following a prevention of future deaths report in which the effectiveness of multidisciplinary team meetings and their governance were highlighted, changes were made to the meeting templates. Staff now had to provide further clarity on the reason someone was to be discussed in the meeting, and that person was to be given feedback on discussions. It is not known if this was being monitored.

The trust held various risk registers. Staff were able to access local risk registers to ensure risks were captured and controls could be put in place to minimise them.

The service fully understood its duty to collaborate and work in partnership, so their services could work seamlessly for people. They shared information and learning with partners and collaborated for improvement.

Staff and senior leaders told us partnerships with other teams, services and organisations were a central foundation of the adult community mental health service’s integrated neighbourhood transformation. They told us neighbourhood leads in the CMHTs helped strengthen existing relationships and identified new ones by linking with local communities and establishing new relationships. We were given numerous examples of support staff gave people to link in with services in their communities. This included services to provide additional support to their health and wellbeing, including food banks, faith groups, support groups, crisis cafes and the local recovery college, among others.

Neighbourhood leads were able to gain a view of need across the service and then identify appropriate support. Some neighbourhood lead roles were employed by the trust, and some by the local authority, which helped support inter-agency working across health and social care. Neighbourhood leads facilitated 17 multi-agency networks across Leicester, Leicestershire and Rutland, with over 900 local practitioners working together on local priorities. In 2024/25, neighbourhood leads’ work had resulted in increased connections between local professionals and increased local access to support such as wellbeing hubs.

One of the roles of neighbourhood leads was to support and enable community partners to lead on initiatives to tackle any health and wellbeing issues identified in their area. Some staff told us that supporting community partners to create their own events, such as mental health workshops or awareness events, enabled the trust to contribute to the district’s health and wellbeing plan beyond the provision of its own community mental health services.

People were signposted to a range of voluntary, community, social enterprise and faith services. This helped ensure people had increased support in their communities beyond the support provided by secondary services.

The adult community mental health service worked with other organisations to safeguard people who used services and the public. They participated in multi-agency public protection arrangements to ensure information was shared and risks were understood about people.

Learning was shared between partners. For example, the adult community mental health service linked with the local acute hospital. The acute hospital’s mental health lead shared their observations about the suicide and self-harm they had seen in the emergency department. This led to the service delivering a workshop for emergency department staff about mental health, with the aim to improve their knowledge and understanding of how to help people who presented to them following suicide attempts or self-harm.

Most staff told us the service recognised the need to link with other organisations and partners to provide joined-up care. For example, some staff told us about their links with the local universities, which helped to ensure that students received the appropriate levels of support.

Staff considered how teams and services worked together to provide effective care and treatment. For example, staff identified that in one case, a supported living team had limited knowledge and experience of a person’s needs. They arranged mental health training to ensure staff were able to provide support to the person who lived there. They told us they recognised that supported living staff were highly knowledgeable about the person’s triggers, family situation and daily living habits. The sharing of this knowledge helped improve the person’s care.

The service focused on continuous learning, innovation and improvement across their organisation and the local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

Staff participated in national audits relevant to the service and learned from them. For example, an audit of the psychosis in early intervention (PIER) team led to recommendations to improve the discharge process. Staff told us about how they worked with CMHTs, the assertive outreach team and GPs to ensure smooth handovers when transferring people’s care to them.

There were quality improvement projects in place. For example, the PIER team were leading a project to assess the impact of long-acting antipsychotic medicines on reducing inpatient admission. Early findings from the data collection phase of the project showed that the average number of admissions per year decreased from 2.22 to 0.11 within one year of starting treatment. The project was ongoing at the time of the inspection, and the trust told us the PIER team was planning to use this information to help inform local decision making about medicines.

Other quality improvement initiatives included the introduction of certain job roles. Peer support workers had been introduced across all teams and community connectors were introduced in CMHTs. At the time of the inspection, a ‘front door’ pilot was in progress. Although not completed, it had led to the introduction of community connectors to CMHTs. Most staff told us feedback about this role was positive, particularly the impact of phoning people who were referred to the service rather than just sending them a letter.

The front door pilot aimed to connect people with the right services at the point of referral. Community connectors contacted people to provide signposting and guidance to people whose referrals did not meet the criteria for CMHTs. The pilot used a quality improvement approach to review and risk assess referrals to ensure people received the right level of support. During the pilot weeks in 2024/25, 320 referrals were received. Of those 320 referrals, 43% were supported to access voluntary, community and social enterprise services or their GP and did not require secondary services. A community connector workshop held in March 2025 gave staff the chance to reflect on the development of the role and case studies were shared that showed how community connectors had supported people to access the right level of support in a timely manner. The trust reported that staff were motivated to continue with the pilot.

Quality improvement projects provided opportunities for improved staff satisfaction. Senior leaders told us about a project that looked at the impact of occupational therapy staff being managed in each team rather than by a clinical lead. They told us they found that by introducing a clinical lead to manage them, staff retention and workforce development opportunities improved. Therefore, the change was implemented across the service.

Learning from quality improvement projects was shared through storyboards all staff had access to.

The research team presented at adult community mental health service business meetings to keep staff informed of recent developments and opportunities to get involved. Senior leaders told us clinical research and research associate posts were available in the service. We were told about the research one staff member was doing into connecting people who used services and carers who spoke languages other than English together.

As part of its suicide prevention plan, the trust had introduced an annual medicines amnesty where people could return any unused medicines. The trust’s data showed the most common method of suicide was through opioids and overdoses. As part of the suicide prevention plan, clinical staff were reminded of the importance of identifying an accurate list of people’s medicines and checking these against what they had available to them, to reduce opportunities for people to harm themselves.

The assertive outreach team was involved in national improvement work with NHS England to support nationally mandated reviews of integrated care boards’ community services for people with serious mental illness, who required intensive community treatment and follow-up but where engagement was a challenge. They contributed to the development of a maturity index toolkit for NHS trusts to use. The maturity index tool helped trusts assess their current assertive outreach services and identify any improvements needed to meet best practice. The trust established a steering group to help review the service and identified actions that it needed to complete.