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 well-led as requires improvement. At this inspection the rating has changed to good.

Leaders had the skills, knowledge and experience to perform their roles. At the HBPoS patients did not stay longer than the legally permitted period. The crisis resolution and home treatment team were meeting the service standards for responding to people who used their services. Teams had access to the information they needed to provide safe and effective care. Staff collected and analysed data about outcomes and performance. They used this to identify improvements. However, we found some concerns with the service. There were inconsistencies in medicines reconciliation, and people were not always 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.

This service scored 71 (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. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The trust’s senior leadership team had successfully communicated the trust’s new vision and values to the frontline staff in the service and staff could describe these and how they applied to their team. Themes from this fed into staff appraisals.

Staff could explain how they were working to deliver high quality care within the budgets available. Mangers told us this was focused on development of staff and their competencies. Managers and staff gave us multiple examples of staff undertaking further training and developing in their roles.

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 crisis services and health outcomes for people who used services.

The trust had introduced its 2025-2030 strategy in partnership with other organisations. 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 deliver care, treatment and support and embody the culture and values of their workforce and organisation. They have the skills, knowledge, experience and credibility to lead effectively and do so with integrity, openness and honesty.

Leaders had the skills, knowledge and experience to perform their roles. We spoke to senior leaders and managers who had considerable experience in the roles they were managing. This helped ensure they understood the potential impact of decisions they made. Team and service managers had held their roles for at least a year, and most had developed into the role within the trust.

We spoke with senior leaders and directors. They demonstrated a good understanding of the services they managed, including their challenges and their achievements. They could explain clearly how the teams were working to provide high quality care. Staff told us that leaders were visible and approachable. Leaders spoke to the inspection team with openness and an ability to reflect on where parts of the service needed to improve.

Managers and senior leaders were visible to staff, with many based in the same offices at the different locations. The service manager was based in the same office as the crisis resolution and home treatment team. 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. Some other managers had been supported by the service and spoke positively about the opportunities they had been given.

The service fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff told us they knew how to raise concerns and 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.

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 2024 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.

The trust had established Freedom to Speak Up processes. The trust had carried out an internal audit of its Freedom to Speak Up provision, policy and procedures in 2023. The 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 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 2024 and November 2024. Managers at the crisis service told us there had not been any recent whistleblowing in the service.

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who work for them.

Staff were able to apply to work flexibly. The trust had a reasonable adjustments policy in place, a Flexible Working Policy and Procedure, and managers told us their teams felt empowered to speak up and ask for support. Staff and leaders gave us examples of flexible working arrangements that supported people’s personal circumstances such as caring responsibilities and religious commitments. 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.

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) and Spectrum (LGBTQ+).

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.

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.

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, and LGBT+ Equality Learning Sets, Sexual Harassment Awareness training and Active Bystander Programme. The Active Bystander training supported staff to recognise and address any bullying, harassment or victimisation they witnessed.

Governance for the mental health crisis services and health-based places of safety at the trust was generally good. The service mostly had responsibilities, roles and systems of accountability and good governance. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

We found some areas of concern within governance. The crisis resolution and home treatment teams had several vacancies across the teams. There was high use of bank and agency staff.

The service did not always make sure that medicines and treatments were safe. There were inconsistencies in medicines reconciliation and people were not always receiving the recommended monitoring following medicine administration.

Calls made to the urgent mental health helpline (111 service) were usually answered in a timely manner. The crisis resolution and home treatment team were meeting the service standards for responding to people who used their services.

Managers told us the daily morning meeting was useful to escalate immediate concerns and had the right people there to respond to and action concerns. There was a clear governance structure that described how locality management and improvement groups fed into the trust management and improvement groups and then to board level for further assurance.

We observed several meetings across teams. Local managers and leaders attended weekly meetings. There was a clear framework of what must be discussed at a team or directorate level in meetings to ensure that essential information, such as learning from incidents and complaints, was shared and discussed.

Managers and senior leaders were aware of the risks to their service. They maintained and had access to the risk register. Staff concerns matched those on the risk register and issues we found during the inspection were also reflected on the risk register. For example, managers told us staff vacancies were a concern for the service and this was on the risk register.

Staff had access to the equipment and information technology needed to do their work. The trust was moving to complete all of their work on electronic devices.

The trust had business continuity plans for emergencies which were particular to each service. They included plans for loss of staff, utilities and information technology and telecommunications and gave staff clear processes to follow in such an event. The business continuity plans were reviewed and updated regularly. The crisis 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.

Team managers had access to information to support them with their management role. This included information on the performance of the service, staffing and patient care. Staff undertook audits, which were recorded using an online system. For example, managers carried out audits of care records for people who used the service. Learning and opportunities for quality improvement from these were shared with the team.

The crisis 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.

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, the service completed an annual audit on staff knowledge around people who self-harmed.

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

The service had established strong links and partnerships with the community. The service worked well with other providers. The crisis service met with police and attended meetings to discuss high intensity users. Staff were able to refer people to substance misuse services and autism services as needed. Staff did this through their established relationship with the community mental health teams. This meant people were supported in other aspects of their life that may have an impact on their mental health.

Managers and senior leaders from the health-based places of safety (HBPoS) met at interagency meetings to monitor the performance and issues with the HBPoS. These were attended by trust managers, integrated care board members, police, local authority and other trusts.

The service received relevant information of concern from Multi-Agency Public Protection Arrangements (MAPPA) meetings, a UK framework for managing the risks posed by serious sexual and violent offenders. Minutes from these meetings were shared with service and supported to identify risks for the teams.

The service was part of the Leicester integrated care system. This also included local authorities, the integrated care board, primary care, and other organisations. As part of their immediate management review process of serious incidents, a nominated staff member would inform other agencies as required including commissioners and NHSE.

The crisis 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.

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.

There wasa closeworking relationship with community pharmacies.Where consent had been obtainedfrom people, discharge lettersweresent directly tonominatedcommunity pharmacy as well asGPs.This helpedensure that any changes in medicineswerepicked up bythecommunity pharmacies as well asthe GP.

There wasagovernancesysteminplacewithcollaborative working withthe Integrated Care Boardandotherproviders aroundsafetransfer of careof peoplewithin the county.

There was a culture of continuous learning, innovation and improvement across the organisation and the local teams. Staff had opportunities, and were encouraged, to actively contribute to safe, effective practice and research.

Staff were given the time and support to consider opportunities for improvements and innovation and this led to changes. Managers and staff told us about current quality improvement initiatives taking place across the service. Examples included a quality improvement project to increase the number of people who used the service being discussed at a multidisciplinary meeting.

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.

Staff were supported with research, for example we saw new innovative headsets (that deliver transcranial current stimulation) piloted to help treat people with severe depression in the crisis resolution and home treatment teams.

Staff told us there was a good supportive culture, with a weekly teaching programme for all staff. Speakers from outside the organisation were invited to deliver sessions on specialist topics.