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 assessment we rated safe as requires improvement. At this assessment the rating has changed to good.

The crisis resolution and home treatment teams (CRHTT) and mental health urgent care hub (MHUCH) premises were safe, clean, well equipped, well-furnished and well maintained. The CRHTT met the service standards for responding to people who used their services. At the health-based places of safety (HBPoS) patients were not detained beyond the legal permitted period. Staff assessed and managed risks to people who used services and themselves well. Staff understood how to protect people from abuse and the service worked with other agencies to do so. Incident reports and care records showed the service managed safety incidents well. However, at the HBPoS there was no direct access to fresh air. There were inconsistencies in medicines reconciliation, and people were not receiving the recommended monitoring following medicine administration. The crisis resolution and home treatment teams had several vacancies across the teams, and there was high use of bank and agency staff. However the crisis resolution and home treatment teams’ and mental health urgent care hub premises were safe, clean, well equipped, well-furnished and well maintained. Staff assessed and managed risks to people who used services and themselves well. Staff understood how to protect people from abuse and the service worked with other agencies to do so. Incident reports and care records showed the service managed safety incidents well

This service scored 69 (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. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The mental health crisis service and health-based places of safety service had a proactive culture of safety. There had been 5 serious incidents in the service in the 12 months prior to our inspection. We reviewed the details of these incidents and we found the trust had responded appropriately to each incident. Learning was identified and shared with the service.

Staff knew what incidents to report and how to report them. They gave examples of the type of incidents they would report via the trust’s online incident reporting system. We looked at incidents reported between January 2025 and March 2025 for crisis services and health-based places of safety. Staff in the health-based places of safety (HBPoS) reported 13 incidents. Staff in crisis service reported 317 incidents in the same period. The highest number of concerns reported were regarding self-harm or threatened self-harm.

The service monitored the number of incidents reported in health-based places of safety and the number of times rapid tranquilisation was administered.

The trust provided guidance to staff on the Patient Safety Incident Response Framework (PSIRF) and staff received patient safety training as part of mandatory training requirements. The PSIRF 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. 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. PSIRF is the NHS’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents for the purpose of learning and improving patient safety. Across CrisisResolution HomeTreatmentTeams (CRHTT) teams, 99% of staff had completed level 1 and 99% level 2 patient safety training.

There were no ‘never events’ reported by the trust in the previous 12 months. A never event is a preventable patient safety incident.

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 trust told us that there were 70 incidents that met the duty of candour threshold between 1 May 2024 and 30 April 2025 and duty of candour was carried out in all instances 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.

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 rapid response and home treatment teams, and HBPoS team, worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed and monitored. These teams made sure there was continuity of care, including when people moved between different services.

Between July 2024 and January 2025 129 patients were held at the HBPoS under section 136 of the MHA. All patients received an assessment within the 24 hour permitted period. The average time for assessment was 6 hours.

Of these, 14 patients were detained to the HBPoS while waiting for a bed, to ensure there was a legal framework to support assessment and interventions. The average length of patient stays whilst detained under Section 136 of the Mental Health Act in the health-based places of safety from July 2024 to January 2025 was 18 hours and 47 minutes.

Between July 2024 and January 2025, there were 7 cases when a patient remained in the health-based place of safety after their assessment while waiting for a bed, and without being detained to the HBPoS. In all cases, a Mental Health Act assessment had been carried out, the decision had been made to detain the patient, and they were waiting for an inpatient bed.

An AMHP is a role under the Mental Health Act in the UK, referring to a qualified and experienced mental health professional who has been approved by a local social services authority to carry out duties related to the compulsory assessment and detention of patients under the Act.

Data provided by the trust showed the average waiting time for a mental health assessment within the HBPoS from detention under section 135 of the Mental Health Act (MHA) to assessment between April 2024 and March 2025 was 6 hours, which is within the 24-hour period outlined in the MHA. The MHA allows clinicians to extend this period by another 12 hours.

The HBPoS was available 24-hours a day. Staff assessed patients promptly once they arrived at the places of safety. On arrival at a health-based place of safety, patients were searched by the police and any items that may have been dangerous to a person’s health and safety were held in storage. Evidence was seen of incidents being managed in line with Trust policy.

Section 136 is part of the Mental Health Act that gives police emergency powers to take someone to a place of safety. Under section 136 of the Mental Health Act 1983, a person can be detained for up to 24 hours, though this can be extended by a further 12 hours if an assessment cannot be completed due to the patient’s condition. If the patient has not been discharged when this detention period has expired, the patient is deemed to be held and given medication unlawfully unless they have capacity and have consented to stay and be treated.

The trust had a policy which outlined the procedures to be followed for the reception, care and assessment of people subject to detention under section 136 of the Mental Health Act (MHA). This stated that once the lawful period of detention had expired the patient was to be informed of their rights that they are no longer detained under the MHA and the trust was to seek the patient’s agreement to remain and await admission. This was to be reported as an incident and escalated appropriately. If the patient did not consent to remain in the HBPoS then any further action, including whether to continue to detain the patient and provide medical treatment, needed to be based on documented multidisciplinary team discussions.

The manager of the health-based places of safety told us they could access AMHP’s anddoctors to ensure people who used services were assessed under the Mental Health Act 1983 (MHA) in line with legislation. After the assessment had been carried out and 2 medical recommendations obtained, the ‘bed-flow’ team was asked to locate an inpatient bed. However, they also told us that if a patient had been assessed as needing an inpatient bed, there were delays finding beds in the inpatient services and so the patient would have to remain in the HBPoS until a bed was found. The service had clear criteria to describe which patients they would offer services to.

Both suites in the place of safety and the room in the mental health urgent care hub (MHUCH) were suitable for adults. The hub is based at the Bradgate Unit for people with mental health needs that don’t need any physical health support from an emergency department. If an assessment finds that a person needs inpatient support, they are transferred to an appropriate ward or appropriate support in the community would be arranged.

Staff used one of the two suites in the place of safety, which had a single bed, to accommodate patients under the age of 18. Staff told us the youngest patient they had admitted was 14. Where a patient was younger than 14, staff said they would consider using the child and adolescent mental health ward on the same site; this is stated within the Trust Standard Operating Procedure.

The service did not accept patients when there were concerns about their physical health. The police took these patients to an emergency department of an acute hospital for medical assessment before taking them to the place of safety.

There were interagency quarterly meetings to monitor the performance and issues with theHBPoS. These were attended by trust managers, integrated care board members, police,local authority and other trusts. We reviewed actions from these meetings.

Staff worked with community teams to ensure continuity of care. Across the rapid response and home treatment teams, staff involved all the necessary healthcare and social care services to ensure people who used services had continuity of safe care, both within the service and post-discharge. The CRHTT service acted based on feedback from their patients and had recently undertaken a quality improvement programme to improve continuity of care for patients which had reduced the average number of staff each person saw from 8 staff to 2.3 staff per person.

Staff followed the trust policy on people who did not attend or did not answer when staff attended their residence. The policy provided a framework for staff to follow in such circumstances and was based on a trauma informed approach to care and treatment. Staff followed a process including contacting the person, their next of kin and they left a card to contact the service due to the person not being there. If no contact was made during the shift, the rapid response team would be asked to complete a welfare check, and if they could still not establish contact the person would be reported as missing to the police.

The rapid response and home treatment team’s service’s referral and admissionprocesses ensured that all essential information about people who used services wasreceived to determine if their needs could safely be met.

Staff reviewed essential safety and risk information about people who used services intwice daily multidisciplinary meetings. These meetings included plans to safely meetpeople’s needs and discharge planning. We observed these meetings and saw robust riskdiscussions of each person on the team caseload. Staff demonstrated a good understandof each person’s risks and planned care and treatment.

Teams used systems to categorise risk each day and identify high risk people who usedservices, and took appropriate action to support these people. We reviewed 24 records forpeople using the rapid response and home treatment team services. They showed riskassessments were completed, reviewed, updated when new information was received,and they were used to support care and treatment.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Staff from the crisis services understood how to protect people and patients from abuse and worked well with other agencies to do so. Staff told us they could access support from the trust’s safeguarding team when they needed it. This included working in partnership with other agencies. Staff reported good working relationships with local authority safeguarding teams and had worked with other agencies, such as the police, to safeguard people.

Staff had training on how to recognise and report abuse and they knew how to apply it. At the time of our inspection, 98% of staff had completed their safeguarding adults level 2 and level 3 training, and safeguarding children level 2 training.

Staff knew how to recognise adults and children at risk of or suffering from harm. Managers of the crisis and home treatment services told us the main safeguarding theme for people who used their services was child welfare. We observed staff identifying safeguarding concerns during the morning planning meetings. Staff knew who the trust leads for safeguarding adults and children were and how to contact them for advice. Managers received alerts for each safeguarding referral so they can keep track of them. Managers reviewed alerts within 48 hours to follow up on outcome and learning. The service had a safeguarding policy that included an escalation process.

The service worked with people to understand and manage risks by thinking holistically. Staff assessed and managed risks to people who used services and themselves well and followed best practice in anticipating, de-escalating and managing challenging behaviour. Staff at the health-based places of safety (HBPoS) used restraint and seclusion only after attempts at de-escalation had failed. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff carried out comprehensive assessments of people who used their services’ mental and physical health needs. We reviewed 30 patient care record across the rapid response and home treatment teams and health-based places of safety (HBPoS). These showed risk assessments were completed and updated regularly and appropriate risk management plans put in place. They showed people who used services were involved in their risk management plan with their views highlighted and a strengths-based approach used in line with their care plan.

We reviewed 24 patient care records for the crisis and home treatment teams. All records had a care plan. Staff formulated an initial care plan with people who used services when they were admitted into the service. Carers and family members could be included in this if the person consented. All records we reviewed demonstrated people who used services and their carers involvement. Staff reviewed and updated care plans weekly or when people’s needs changed. All records we reviewed had a safety plan in place. Mangers carried out a monthly care record audit which focused on risk assessment, care and crisis planning. Staff involved people who used services in care planning. We found evidence of people who used services and carer involvement in all care plans we reviewed. Care plans were written in a way that people who used services could understand. We spoke to 6 people who used the crisis services. All the people we asked about care plans had copies of their care plans and understood them.

Medicines care and treatment plans were well documented throughout people’s care records. They were detailed and included information about physical health monitoring, side effects and actions for staff to take to ensure people were kept safe when taking medicines.

Staff performed a full physical health assessment on people who used services. The teams had physical health nurse in place who also took the lead on wellbeing.

At the HBPoS, the duty doctor completed physical health screening of all patients who gave consent. Patients had their physical health assessed prior to admission to the HBPoS and were taken to the emergency department for any concerns before admission. Patients had their physical health monitored closely while they were in the HBPoS.

Staff demonstrated their understanding of the use of restraint or restrictive practices as a last resort. Managers at the rapid response and home treatment teams told us that restraint or restrictive practice was not used by the service. The trust provided data on restrictive practice in the place of safety between November 2024 and April 2025. In that time there had been one incident of rapid tranquilisation and 6 incidents of physical restraint. Staff undertook restraint training. At the time of inspection 100% of staff in the crisis service had completed this.

At the HBPoS there was no direct access to fresh air. However, the service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

At the health-based places of safety (HBPoS) all clinical premises where patients were seen were safe, clean and well maintained. Staff visited most people at their homes or in community settings. The crisis service had a room on premises that was part of their mental health urgent care hub where people could be seen, however managers told us this rarely happened as most people elected to be seen in their homes. These rooms were clean and fit for purpose.

The mental health urgent care hub had been refurbished recently. The new hub space was made ligature free and had been co-designed with an expert by experience within the Trust.

The layout in the health-based places of safety (HBPoS) allowed staff to observe all areas. There was closed-circuit television (CCTV) which allowed staff to observe internal and external patient areas. There were no potential ligature anchor points, and each HBPoS had completed a ligature risk assessment. There was a comprehensive environmental check list that was completed weekly.

At the HBPoS, all the facilities were clean and tidy. Staff cleaned and checked the rooms after each patient was discharged.

However, at the HBPoS patients had no direct access to outside space and fresh air, though this could be facilitated based on individual need and risk assessment as and when required.

The place of safety consisted of 2 suites with showers and toilets. One suite had a fixed single bed and chairs, and the second suite was set up on the day of inspection with a bean bag and soft chairs to enable the space to be used as a seclusion area if clinically indicated. If the second suite needs to be used as a bedded facility, then a non-fixed bed is available.

Staff had easy access to alarms including wearing personal safety devices that connected them to each ward, and lone worker devices.

Staff did regular risk assessments of the care environment, and all buildings had a local site-specific risk assessment. We reviewed the site-specific risk assessment for all of the home treatment teams and HBPoS.

Clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly. Staff checked equipment and temperatures daily.

Staff completed and regularly updated thorough risk assessments of all areas and removed or reduced any risks they identified. Annual environmental risk assessments were completed for each of the home treatment team sites.

The service had high vacancy rates, and bank and agency staff use. However, people who used the service still received safe care. Staff completed mandatory training and the service made sure staff received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

At the time of our inspection there were several vacancies across the CrisisResolution HomeTreatmentTeams (CRHTT).

When necessary, managers deployed agency and bank nursing staff to maintain safe staffing levels. Data the trust provided to us showed that between February 2025 and April 2025 in the crisis service 1,312 shifts were filled by bank staff, and 599 shifts were filled by agency staff.

The service used bank and agency staff to fill gaps in shifts due to leave or sickness. Between May 2024 and April 2024 the staff sickness rate was 4% for the mental health urgent care hub, 8.7% for the CRHTT and 12% for the central point of access (CPA) team. The CRHTT and CPA teams were above the trust target of 4.5%. The overall trust staff sickness rate between April 2024 and March 2025 was 5.5%.

Between May 2024 and April 2024 the staff turnover rate was 8% for the mental health urgent care hub, 5% for the CRHTT and 2% for the CPA team which is within the Trust target of 10%.

Several substantive staff were in the bank pool of staff and filled shifts within their team. Managers told us due to the specific work of the teams they preferred staff who had worked within this or another crisis service before. Managers gave all temporary, agency and bank staff a local induction if they had not worked at the service previously. All staff were first required to work a shadow shift. This is a shift where the new staff member shadows a current staff member to observe and learn about the role. The service had an induction book that included a checklist, policies, requirement for care record completion, and the process to follow if they were unable to make contact with a person who used the service. Whenever possible, the service used long-term agency staff who were familiar with the service.

We raised concerns about staffing levels during our inspection. Managers and senior leaders were very aware of the risks due to staffing vacancies, and they told us this was the top risk for the service. Managers told us there was ongoing recruitment with appropriate recruitment initiatives, and new staff were due to start. If there was a short notice unfilled shift this was reported as an incident. The data provided by the Trust showed there were no unfilled shifts. Managers and senior leaders told us recruitment was difficult due to the geographical area that was covered by the service, and delays in onboarding new staff

Mandatory training was comprehensive and met the needs of staff and people who used services. All of the staff we spoke to told us they were up to date on their mandatory training. The crisis service consisting of the central access point team, the mental health urgent care hub, the staff at the place of safety and the home treatment teams were at 97% compliance with their training. Team managers told us that regular agency and bank staff also completed trust mandatory training.

Managers and staff told us they received combined clinical and managerial supervision every 6 weeks. The crisis service was at 95% compliance with supervision. The crisis service had a supervision tree where senior members of the team provided supervision for junior members of staff. Managers told us staff discussed clinical cases during supervision. Staff also did reflective practice during daily multidisciplinary meetings. Bank and agency staff were also offered supervision.

Managers identified the learning needs of staff and provided them with opportunities to develop their skills and knowledge. For example, managers and staff told us they had identified a need for further training to support autistic people and people with a learning disability due to the increase in people presenting with these diagnoses.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

We looked at clinic rooms, consultation rooms and reception and waiting areas at the locations we visited. All were visibly clean and tidy.

Cleaning records were up to date and demonstrated all areas were cleaned regularly. The service had appropriate policy and guidance for staff to follow in relation to preventing and controlling infections.

The service did not always make sure that medicines and treatments were safe. However, the service ensured medicines and treatments met people’s needs, capacities and preferences. They always involved people in planning, including when changes happened.

Although the CRHTT had a physical health nurse as part of team, there were inconsistencies in medicines reconciliation (the process of accurately listing a person's medicines) when people were admitted to CRHTT. Information documented was sometimes incomplete and did not follow CRHTT standard operating procedure. However, to address this the Trust had taken the step to recruit additional pharmacy technicians to release clinical time.

Staff reviewed the effects of each person's medicines on their physical health. However, people commenced on anti-psychotics while under the care of the CRHTT did not have physical health monitoring in line with NICE Guidance. The trust provided evidence that an audit from May 2025 showed an improvement from December 2024, and 80% of people commenced on anti-psychotics while under the care of the CRHTT had physical health monitoring in line with NICE Guidance. There was a physical health register, whereby people could be sent reminders to have their physical health checks undertaken with results going to prescribers. However, people under the care of CRHTT were not included on this register. This meant people not receiving the recommended monitoring were at risk of developing physical health issues due to adverse effects from these medicines. This gap had already been identified by the service and was on the local risk register, with governance oversight. To address this, the service had made several changes, for example, increased the number of staff trained in phlebotomy and invested in portable ECG machines.

However, the service had systems and processes in place to safely support people with their medicines when accessing the health-based place of safety (HBPoS). Medicines were stored safely and securely and there was access to emergency medicines. There was a clear audit trail of medicines which had been issued by Crisis Resolution Home Treatment Teams (CRHTT) staff to people that use the service.

People’s medicines were regularly reviewed by themultidisciplinary team (MDT)while under the careofCRHTT. Concerns could be escalatedatdailymeetingswhere cases werediscussed andreviewed.Actionswereput in place to ensure people remained safe with their care and treatment.

There was a focus on collaborative working withgeneral practitioners(GPs)andlocalacute trusts to promote the safe care of people’s prescribed medicines. Staff had access to GP care records,includingpeople’s current medicinesandphysical healthtestresults.This meant they could make informed decisions about care and treatment and had access to the most up to date information available.Electronic alertssetup by the GPunder people's case notes,werevisible to all staff. For example,in one case we sawaGP had set an alert for apersonwhowas known tostockpilemedicines.This meant CRHTT staff wereable tomonitorthequantitiesof medicinesduringhomevisits.

Medicines information was available to people in different languages and in easy read formats. Additionally, staff carried paper information leaflets with them during home visits where digital access was not easily available. Remote clinical advice and support was available for staff when they carried out visits to people's homes.

However,we saw oneexamplewhereadviceondiscontinuinga hypnotic medicine hadnot been escalated toan appropriatelyqualified memberof staff.This meant the personhadnot receivedthe mostaccurateinformation about their medicine.

The trust usedePACTdata (Electronic Prescribing and Cost Tool) to help provide assurance that prescribing was within the scope of the service.Any deviations in prescribing wereidentifiedandfollowed up with service leads.The trust worked collaboratively with other providers and were part of theLeicester,Leicestershireand Rutland Area Prescribing Committee (LLR APC).Theyoutlined the responsibilities ofprescribing and monitoring ofmental healthmedicines in the county.Thisalsomeantpeoplehadaccesstotheir medicines closer to home.

Medicines errors and incidents were discussed regularly by staff within the trust and learning from these was shared widely with the service. There was evidenceoflearning fromnationalincidentswhich wasshared acrossteams.