Leicestershire Partnership NHS Trust

On this page

• 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 responsive as requires improvement. At this inspection the rating has changed to good.

The service made sure people who used services could access care and treatment in a timely way. It met the national standards for assessment of emergency crisis referrals and calls to the 24-hour mental health helpline were answered in a timely way. Staff supported people who used services to access activities outside the service, such as work, education and family relationships. The service met the needs of people who used services with a protected characteristic and staff helped people with their communication needs. The service treated concerns and complaints seriously, investigated them and learned lessons from the result.

This service scored 79 (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 and they decided, in partnership with people, how to respond to any relevant changes in people’s needs.

All people and patients we spoke to said that staff understood their individual needs including cultural and religious needs. Staff helped patients with communication and their social issues, such as homelessness and access to services.

Staff discussed people who used their services’ specific needs in daily morning planning meetings. Staff made sure people could access information on treatment, local services, and how to complain.

Staff from the rapid response and home treatment teams were able to record in the people who used this service care records their individual needs and preferences, and whether they had any communication or accessibility needs.

The service understood the diverse health and care needs of people and their local communities, so care was joined-up and flexible.

The crisis service ensured that families and carers had opportunities to be involved in the care and treatment of the people who used their services, with their consent. Families and carers were usually present during home visits by the team. Staff told us that they knew it was important to involve carers and families as they were able to provide contextual information on a person that would benefit formulating their care plan.

Staff in the service could access support from dedicated carers leads to ensure carers were provided with information about support services and their rights. The service was in the process of embedding the Triangle of Care to formulate care plans. Managers told us the patient care involvement team were taking the lead on this. The service had Triangle of Care champions to support staff in using this. Senior leaders told us managers will then use the results to improve care. The Triangle of Care is an improvement tool based on 6 principles to ensure providers include and support unpaid carers.

The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

Staff across the crisis service ensured that people who used services could obtain information on treatments, local services, rights and how to complain. There were notice boards and leaflets in service user-areas and people were given information about other services as part of their assessments. Other languages were available for people through a QR code that was on staff lanyards. The service also had a list of staff who were bilingual and were happy to support people who used their service with their language skills.

Staff communicated with people who used services so that they understood their care and treatment, including finding effective ways to communicate with people with communication difficulties. People we spoke to told us the service made an effort to meet their communication needs.

The trust website met accessibility standards and information could be easily accessed by making it larger or changing colours and fonts. Information on how to access crisis services was in simple text, with pictures. Staff could access information on the pharmacy intranet page in other languages, large print and easy read format to ensure people who used services were given appropriate and accessible information on the medicines they were given.

Staff at the service made notifications to external bodies where relevant. Managers told us that they made all necessary notifications to external bodies, for example, to the police when managing a high intensity user of the service.

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

The service had a clear structure in place to manage complaints. The service treated concerns and complaints seriously, investigated them and learned lessons from the results, and shared these with the whole team and wider service. Complaints were managed by the clinical governance team. Complaints were investigated and the complainant was contacted for their input. Managers attended local mental health networks and spoke with Healthwatch to gain 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.

The home treatment team listened to and understood people’s needs, views and wishes. The service used the friends and family test to obtain feedback from people who used the service and carers. Managers told us this did not have a big uptake, Managers told us that people who used the service and their families and carers could contact the service to provide feedback. Staff encouraged people to use this method to feedback any concerns. The outcomes from these feedback sources were discussed and the feedback received from this was reviewed and used to improve the service. For example, feedback was that carers would like to be included in care planning with the consent of the person using the service. Staff then ensured carers and families were given the opportunity to plan care collaboratively.

People we spoke to said they would feel able to raise a concern or complaint if they needed to. However, in some of the feedback provided in the CQC 2024 Community Mental Health Survey, people told us they felt the service could improve by listening to complaints and actioning any necessary changes.

Staff knew how to handle complaints appropriately. They were aware of the complaints process and how to support people who used services to raise concerns or make a complaint. People we spoke to said they either knew how to make a complaint or would contact the service to find out how if needed.

Between 1 May 2024 and 4 May 2025, the crisis service received 10 complaints. Of those 10 complaints, 1 was upheld, 4 were partially upheld and 1 was not yet closed. Four complaints were not upheld. Staff and senior leaders told us the biggest causes of complaint were communication and people not feeling heard. The service’s complaint data showed that ‘patient care’ was the most common complaint topic. Of the 10 complaints received, none were referred to the Parliamentary and Health Service Ombudsman. Between 1 May 2024 and 1 April 2025, the crisis service received 73 compliments.

Managers told us that a reason the number of formal complaints for the teams were low was because they were proactive in contacting people when concerns were raised, so that issues could be addressed quickly.

Managers shared feedback from complaints with staff and learning was used to improve the service. Complaint themes and learning were shared in governance meetings. Feedback and learning from complaints was shared with staff at team meetings. Feedback from compliments was also shared at these meetings. The clinical governance team monitored all complaints and compliments.

Calls to the urgent mental health helpline (111 service) were answered in line with National performance. Between 1 May 2024 and 30 April 2025, the average of the percentage of calls dropped was 17% compared to the 27% national average. The service met the national standard for assessments within 4-hours of an emergency referral.

At our last inspection, we found the service did not always meet the national standard for 4-hours from emergency referral to assessment. Data provided by the trust showed that for the period April to August 2017 an average of only 32.5% of all referrals were assessed within 4 hours. At this inspection the service met the 4-hour target to urgent assessments. Between April 2024 and March 2025, the average rate of compliance with the 4-hour target was 1.9 hours and 94%. This is above the national average reported in the National Oversight Framework of 63%.

The mental health crisis service was available 24-hours a day and was accessed through a single point of access that was a centralised dedicated crisis telephone line using 111 option 2. Between May 2024 and April 2025, the average rate of abandonment of calls to the crisis line was 18% of calls per month. This was below the national average.

However there were no waiting lists for the home treatment teams. Staff mostly saw people referred urgently for a face-to-face assessment within four hours, and non-urgent referrals within 24 hours. Between April 2024 and March 2025 the average time for people who used crisis services to wait for assessment and treatment was 20 hours against the target of 24 hours. The service had a rapid response vehicle to support people who used crisis services. The vehicle was also used to support triage of these people.

Staff and leaders actively listened to information about people who were most likely to experience inequality in experience or outcomes. This meant services were tailored to meet the needs of individuals and delivered to ensure flexibility, choice and continuity of care.

Staff in the crisis 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 98%. The home treatment teams met the needs of all people who used their service, including those with a protected characteristic. A protected characteristic is one that is protected by law against unfair treatment or discrimination. We spoke to 9 people and patients and those that had protected characteristics felt the services had incorporated these into their care.

Staff across the crisis service told us about the diverse needs of their populations. They understood how this could impact people’s experience of care and treatment. Some staff told us examples of ways in which the crisis service supported people to have equitable experiences and outcomes. For example, managers told us the service had 2 neurodiversity leads to support people’s neurodivergent conditions when planning appointments. The service had also created sensory bags to take to appointments for the people who used the service.

A Joint Strategic Needs Assessment (JSNA) was developed for Leicester and this provided recommendations to inform decision making for services that would benefit the population. A JSNA is a statutory process by which local authorities and commissioning groups assess the current and future health, care and wellbeing needs of the local community to inform decision making.

The trust had a group strategy called THRIVE which stood for technology, health communities, responsive, including everyone, valuing our people and efficient and effective. As part of this strategy the mental health directorate held workshops to looking at the experience of homeless people in the service and what could help. This included providing joined up communications from the relevant health care services, and seeing the same staff regularly. The service had a health and inequality framework that had been recognised nationally as best practice.

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 crisis 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.

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 community mental health teams’ sites.

People were supported to plan for important life changes, so they could have enough time to make informed decisions about their future.

Staff supported people who used services to make informed choices about their care and plan their future care and treatment. Staff created personalised care and safety plans for people who used services, and accounted for their needs, wishes and feelings. Care plans we reviewed showed this and were recovery focused.

Discharge planning began at the initial assessment. The service used audits to check that all care plans had a clear discharge date. We reviewed 24 care records for this service and found that discharge planning had been considered for all people who used the service.

People told us the service helped them plan what to do if their condition deteriorated and ensured they had contact details to use if this happened.

Staff ensured all relevant healthcare professionals and other relevant bodies were involved in planning the care and treatment of people with complex needs. Staff were able to refer to other teams and services if appropriate, such as autism services.