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 this key question as requires improvement. At this assessment the rating has changed to good.

The service fostered a positive safety culture where staff were open, honest and willing to learn. Safety concerns were listened to, incidents were investigated and reported appropriately, and learning was used to improve practice.

Staff worked collaboratively with people and partner organisations to maintain safe systems of care and ensure continuity, including during transitions between services. They engaged with children, young people and families to understand what safety meant to them and safeguarded them from harm, abuse, discrimination and neglect.

Risks were assessed and managed well, and staff followed best practice in anticipating and responding to challenging behaviour. Concerns were escalated promptly, and care was delivered in a way that was safe, supportive and centred on what mattered to people.

However, the service did not always identify or control environmental risks, and equipment, and facilities did not always support safe care. Infection prevention and control risks were not always effectively assessed.

Medicines and treatments were managed safely, and people were involved in planning their care, including when changes occurred.

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. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Staff recorded incidents on an electronic incident record. Between January and March 2025, there were 63 incidents. For these 63 incidents the highest reporting cause groups were self-harm, communication and missing patients.

Incidents were investigated in accordance with the NHS framework. More serious incidents were escalated to senior levels in the trust. Between January and March 2025, 7 incidents were escalated but none of these required further investigation. Managers investigated incidents through a local directorate investigation or, for more serious matters, a patient safety incident response plan. This is consistent with NHS guidance on ensuring proportionate responses to patient safety incidents.

The outcomes of investigations were shared with staff. We saw posters displayed across sites signposting staff to the CAMHS section of the intranet, where they could find information about lessons learned within child and adolescent mental health services. Service managers held daily acuity meetings which included discussing incidents, actions taken and feedback. Monthly learning boards were produced which broke down serious incidents learning into easy-to-read information. A CAMHS quarterly newsletter was produced with lessons learnt and shared across the service.

The service made changes following investigations. For example, a learning briefing described an historic case of a young person who had died. The investigation found gaps in the way information was recorded and shared with other agencies. It also highlighted the need to improve the electronic patient record system, so clinicians can clearly see a child or young person’s diagnoses.

Staff understood their duty of candour. They were open and transparent and gave children and young people a full explanation when things went wrong.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The child and adolescent mental health service (CAMHS) starts with a referral from a GP, school, health or social care professional, or sometimes from the family, giving details of the child’s difficulties and risks. The referral is then screened through a Single Point of Access to determine urgency and suitability for CAMHS support. If accepted, the young person attends an initial assessment to identify needs and plan treatment. Only the most severe or high‑risk patients progress to inpatient care when community support is insufficient.

Staff follow the CAMHS Complex Care Escalation process which involves teams of multiagency staff working together to ensure young people are placed at the centre of all decisions and actions.

Registered nurses reviewed the referrals and assigned children and young people to specialist teams. The specialist teams focused on eating disorders, services for young people, paediatric psychology, learning disability, crisis and home treatment services, generic outpatient appointments, primary mental health and intensive community support.

The service worked collaboratively with other services to ensure that children were supported. For example, staff worked closely with schools to provide guidance on managing emotional needs in the classroom and to address issues such as attendance, bullying or exam stress. Another example was the provider worked in collaboration with Leicester City Football club and provides Play on Programme. This programme specifically supports equality and bridging the gap for children and young people with ethnically diverse backgrounds, deprivation and other inequalities.

Staff supported patients to plan for future changes, discharge and ongoing support. Children and young people were discharged from CAMHS when they no longer needed support, when their treatment had finished, or when they were referred to another service (such as adult mental health services when they turned 18). The decision to discharge was made collaboratively between the patient, their family and the service. Before patients left the service, staff made a simple plan that provided details of further help and support.

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 children and young 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.

Between 1 November 2024 to 1 November 2025, 45 multi agency referrals were made by the service to local authority children’s safeguarding team. There were 289 contacts made by the service to the trust safeguarding team for advice and guidance.

The trust had policies on safeguarding children and young people in place. Policies operated in line with statutory NHS requirements, including the NHS England Safeguarding Accountability and Assurance Framework, which outlines clear expectations for duty of care, risk assessment, and effective multi‑agency cooperation.

Staff were offered safeguarding supervision for advice and guidance on cases, in a group setting or with a line manager. Attendance was mandatory. Staff could attend face to face drop-in safeguarding sessions every month with the trust safeguarding team, alternating between the three sites.

Staff had completed mandatory safeguarding training. Compliance rates were above the target for the trust across both children’s and adults’ safeguarding levels: 99% for children’s levels 1 and 2, and 96% for level 3. For adults’ safeguarding, compliance was 99% at level 1, 98% at level 2, and 93% at level 3.

The service worked with children and young people to understand and manage risks by thinking holistically. Staff assessed and managed risks to patients and themselves well and followed best practice in anticipating, de-escalating and managing challenging behaviour. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

During periods of waiting, staff worked with children, young people and their families to identify, understand and manage risks. This included providing safety information, agreed escalation routes and advice on accessing urgent and crisis support.

We reviewed 19 safety management plans. The risk management template required staff to record risk factors (personal, family, social), details of instances of harm to self /others, other risks, formulation and a management plan. Safety management plans were tailored to each child or young person’s circumstances, using language and methods appropriate to their age and ability. From this, agreed, clear and understandable safety plans were developed. Staff actively involved children and young people and their families in identifying, understanding, and managing risks in a holistic and supportive way. We found the child or young person’s voice was amplified in this person-centred approach. The risk management plans were reviewed regularly with the child, their family, and the care team. We saw crisis risk management plans were completed at access appointments and reviewed within the agreed timescales.

Staff operated a clinician-led managed waiting list system to ensure oversight and safety for children and young people awaiting further assessment or information. Those identified as red (high risk) were allocated a named lead professional. Children or young people assigned a risk rating of amber or green were supported through a duty system, providing shared oversight among clinicians.

When children and young people did not attend a scheduled face-to-face appointment, staff followed the provider’s ‘Did Not Attend’ policy by contacting carers within 15 minutes to confirm their whereabouts. Staff reported that this proactive approach was effective and made a significant contribution to keeping young people safe.

The service did not always detect and control potential risks in the care environment. They did not always make sure equipment and facilities supported the delivery of safe care.

We visited 3 sites, Westcotes House, The Valentine Centre and Loughborough hospital. Westcotes House is a large site and includes three separate buildings known as Westcotes House, Artimis House and Westcotes Lodge. Both Artimis House and Westcotes Lodge were large, modern, clean and well maintained. However, Westcotes House was in a poor condition. Carpets were worn or stained and some of the furniture was worn. The trust reported plans to replace the carpets with suitable flooring within 6 to 8 weeks. One meeting room had significant ceiling cracks and a damp odour. A technician assessed this on 28 November 2025. Plaster repairs were scheduled within six weeks. A large group room for children and young people had multiple dark carpet stains caused by a leaking roof. The trust stated that a new roof was scheduled for installation in January 2026. A further room had a badly stained carpet. Another room contained a torn settee and an unclean bean bag. There was no cleaning schedule in place. At Artemis House, several bean bags had non‑removable coverings, and the frequency of their cleaning was unclear.

During our site visit, we observed a used needle on the grounds adjacent to the outdoor stairs. We raised this matter with the service manager. The service took immediate action to clear this area and remove any risks.

The environment at Loughborough Hospital appeared bland and not especially suitable for children and young people. Colour schemes were plain throughout, and meeting rooms looked identical, with bare walls and minimal child‑friendly features. Each room contained a small child’s desk alongside full‑sized tables. Overall, the environment gave a general impression of needing light refurbishment, including fresh paintwork, bathroom modernisation, and replacement of some worn furniture.

At the Valentine Centre the environment had been adapted to meet the needs of children who used the service. For example, white noise was played in some meeting rooms. (White noise is a steady sound containing all audible frequencies at equal intensity similar to static or a fan. It masks other noises and is often used for ensuring confidentiality and privacy). Staff reported estates issues. These included a leaking roof and one toilet emitting a strong sewage smell. The estates team were aware of these concerns and were taking action.

All clinic rooms across sites were appropriately equipped for physical examinations. The Valentine Centre and Westcotes House did not have clinic room checklists in place.

Staff carried personal alarms to use in emergencies. Meeting rooms did not have fixed alarm systems, except for the crisis meeting rooms where emergency buttons were installed. At Westcotes House, a reception‑based alarm system was in place and linked directly to the police station.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Between November 2024 and October 2025, staff sickness rates at the Valentine Centre ranged from 4% to 10%. In October 2025, sickness rates were 2% at Westcotes House and 3% at Loughborough Hospital. The trust’s target for sickness rates was 5% or lower.

Service managers could adjust staffing levels. Where leaders determined that staff absence was impacting patient safety or service delivery managers sought to backfill with appropriately qualified and experienced staff. Where appropriate to do so, substantive staff were offered the opportunity to work extra hours. On average, the equivalent of 0.6 full time equivalent (FTE) per month was filled by substantive staff working additional hours between November 2024 and October 2025. The majority of this was within the registered nursing staff group. Utilising the trust substantive staff helped ensure continuity of care.

When necessary, service managers deployed agency and bank nursing staff to maintain safe staffing levels. Between November 2024 and October 2025, Loughborough Hospital reported low usage, with bank staff at 1–2% and agency staff at 1%. The Valentine Centre had higher reliance on temporary staffing, with bank usage at 2-8% and agency usage between 1-8%. Westcotes House did not use any bank or agency staff.

Managers 'block booked' bank staff when there was a shortfall in a team's establishment. At the Valentine Centre, one bank nurse worked consistently in the same team for most of the year, and one bank healthcare assistant worked continuously for five months, alongside other bank healthcare assistants who covered shifts as required. Service managers for the crisis team had block‑booked five long‑standing agency staff. These staff had worked with the team for five years. They were inducted, trained and supervised to the same standard as substantive staff. The team also maintained a core group of inducted bank staff who provided support during periods of high patient acuity or increased referrals.

The highest staff turnover was at the Valentine Centre at 14%. The crisis team and Intensive community support team (ICST) had seen increased activity relating to staff turnover with staff leaving and staff promoted. The staff turnover rates in total were 9%. Staff work across Westcotes House and The Valentine Centre site with Loughborough Hospital operating as a satellite venue.

Staff had received and were up to date with appropriate mandatory training. Training compliance rates ranged from 89% to 100%. The expected compliance rate was 85%. Mandatory training included paediatric resuscitation level 2, resuscitation level 2 (basic life support), preventing radicalisation level 3 and fire safety awareness. Staff completed the Oliver McGowan mandatory training on learning disability and autism (parts 1 and 2). Training comprised of three components: e‑learning, part 1, and part 2. Compliance rates were 94% for e‑learning, 100% for part 1, and 90% for part 2.

The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

The trust assessed and managed the risk of infection, detected and controlled the risk of it spreading and took prompt action where additional cleaning was required. Staff kept the sites mostly clean and well maintained.

There have been improvements since the last inspection. However, staff did not consistently follow infection prevention and control principles. At Westcotes House, one clinic room was unclean, prompting immediate cleaning and the introduction of daily room checks. Across sites, toys, bean bags and cleaning rotas were not routinely completed, reflecting issues previously identified at the 2018 inspection. Westcotes House and Artemis House lacked cleaning schedules for bean bags, and at Loughborough Hospital, toys were not cleaned in line with policy, and the cleanliness rating poster had expired.

Infection prevention and control training was provided at Levels 1 and 2. Infection control compliance at Level 1 was 100%, with all 15 eligible staff completing the training. At Level 2, 168 of 169 eligible staff completed the training, resulting in a 99% compliance rate. Both levels exceeded the trust’s expected compliance rate of 85%. An infection control audit from November 2024 to November 2025 showed that staff adhered to established infection control principles, including effective hand hygiene.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involve people in planning, including when changes happen.

During this assessment, there were no medicines held across sites. Within the staff team there were doctors and non-medical prescribers to prescribe medicines. A non‑medical prescriber (NMP) is a qualified healthcare professional who is not a doctor or dentist but has completed specialist training that allows them to prescribe medicines within their scope of practice.

Staff conducted a full assessment of patients, including both their physical and mental health, before prescribing medicines.

Staff reviewed the effects of medication on children and young people’s physical health regularly and in line with National Institute for Health and Care Excellence (NICE) guidance, especially when the patient was prescribed a high dose of antipsychotic medication.

Decisions regarding medicines were discussed within the multidisciplinary team, ensuring that prescribing was clinically appropriate and aligned with national guidance and best practice for child and adolescent mental health services. Where young people had fluctuating or impaired capacity, staff completed timely capacity assessments and clearly recorded the rationale and outcomes in care records.

Children and young people and where appropriate, their parents or carers were involved in discussions about treatment options. Staff ensured information was offered in an accessible and age‑appropriate manner to support understanding and informed decision‑making. We saw examples of staff adjusting treatment plans to reflect young people’s preferences, therapeutic goals and individual circumstances.