Leicestershire Partnership NHS Trust

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• 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

This means we looked for evidence that the service met patient’s needs.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good. This meant patient’s needs were met through good organisation and delivery. The design, layout, and furnishings of the service supported patients’ treatment, privacy and dignity. Staff supported patients with activities outside the service, such as work, education and family relationships. The service met the needs of all patients – including those with a protected characteristic. Staff helped patients with communication, advocacy and cultural and spiritual support. The service treated concerns and complaints seriously, investigated them and learned lessons from the result.

This service scored 75 (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 ensured that patients were at the centre of their care and treatment choices. Staff worked in partnership with patients to decide how to respond to changes in needs and preferences.

Staff ensured that care was planned and delivered in line with patients’ individual needs and preferences. Staff empowered patients to make informed decisions about their care and treatment by providing clear information about the options available to them.

Care was delivered as a collaborative process between patients and practitioners, and where appropriate, carers were involved in discussions and decision‑making to support continuity and person‑centred care.

The service provided information in a range of accessible formats to help patients understand their care. This included information available in different languages and the provision of easy‑read materials to support patients with additional communication needs.

The service had an exceptional understanding of the diverse health and care needs of patients and the communities it served. Care was joined‑up, flexible and responsive, and consistently supported choice, continuity and positive outcomes.

Following completion of pathway assessments and the identification of individual needs, staff allocated patients to the most appropriate professional and care pathway. All patients were allocated to a qualified mental health professional, ensuring timely access to specialist expertise and continuity of care.

Staff worked flexibly to support patients to achieve wider recovery goals. Where appropriate, patients were supported to access education, training and employment opportunities. Community connectors played a central role in maintaining ongoing contact with patients and in signposting them to relevant voluntary and statutory services. This helped reduce barriers to care, supported social inclusion and promoted independence.

The adult community mental health service operated in line with best practice, including relevant National Institute for Health and Care Excellence (NICE) clinical guidelines. The service demonstrated a strong commitment to equality, safeguarding and information governance. Staff adhered to local equality legislation and safeguarding frameworks, and the service maintained full compliance with data protection requirements, including the UK General Data Protection Regulation (GDPR) and the Data Protection Act 2018.

We saw strong evidence of effective multi‑agency collaboration with statutory and partner services. This supported integrated, system‑wide working and ensured coordinated responses to complex needs. Information was shared appropriately between agencies, enabling seamless transitions between services and supporting continuity of safe, effective care.

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

Staff made notifications to external bodies as required, including the Care Quality Commission (CQC), local authority safeguarding teams and the police.

Information governance arrangements ensured the confidentiality and security of patient records. The service complied with the Accessible Information Standard and took steps to identify and meet patients’ communication and information needs.

Staff ensured that patients had access to information about treatments, local services, their rights, and how to raise concerns, make complaints or provide compliments. Information was provided in formats appropriate to the patient group, and leaflets were available in languages spoken by patients using the service.

Where appropriate, staff ensured that carers and families were kept informed and updated about patients’ progress, supporting transparency and continuity of care.

The service made it easy for patients to share feedback and ideas, or to raise concerns and complaints about their care, treatment and support. Patients were involved in decisions about their care and were informed about changes made because of feedback.

The provider had a range of mechanisms in place to enable patients and carers to provide feedback. This included a bi‑monthly patient care and experience group meeting. Patients told us they knew how to raise concerns or make a complaint and that, when they did so, they received feedback on the outcome.

Staff understood how to handle complaints appropriately and took steps to ensure that patients who raised concerns or complaints were protected from discrimination and harassment.

Across the 4 teams inspected, the provider received 29 complaints during the six‑month period from July to December 2025. The highest number of complaints (17) related to the Northwest Leicestershire adult community mental health team and concerned patient care, discharge, communication, values and behaviours, and prescribing. The lowest number of complaints (3) related to the psychosis intervention and early recovery (PIER) team and concerned patient care.

At the time of inspection, 25 of the 29 complaint reviews had been completed and 4 were ongoing. Of the completed reviews, 6 complaints were upheld, 8 were partially upheld and 11 were not upheld. The trust identified actions arising from complaints, and team managers monitored the completion of these actions, demonstrating oversight and accountability for learning and improvement. Staff received feedback on the outcomes of complaint investigations and acted on the findings.

The trust also received a high level of positive feedback. During the same six‑month period, the provider received 75 compliments, indicating that positive feedback significantly outweighed concerns and complaints. The highest number of compliments (59) related to the PIER team, and the lowest number (1) related to the City East CMHT.

The provider confirmed that no correspondence had been received from the Parliamentary and Health Service Ombudsman (PHSO) during the 6 month period from July to December 2025, indicating that no reviews were underway and no outcomes had been issued.

The evidence showed a good standard. The service made sure that patient could access the care, support and treatment they needed when they needed it. The service had taken actions to ensure that patients could access the care, support and treatment they needed when they needed it.

The target time between referral and initial assessment for the community mental health teams (CMHTs) was 42 days. At this inspection, we found that waiting times had reduced significantly compared with the reported average of 133 days at the time of the previous inspection. In December 2025, the shortest waiting time was in Northwest Leicestershire CMHT (26 days), followed by City East CMHT (59 days), with the longest wait in East Leicestershire CMHT (69 days). The average waiting time across teams was 51 days. While this remained just above the 42‑day target, it represented an approximate 61% reduction from the previously reported average.

For the psychosis intervention and early recovery (PIER) team, the target time from referral to initial assessment at the previous inspection was 14 days. By December 2025, this had reduced to 7 days, demonstrating timely access to assessment.

The target time from initial assessment to the start of treatment for CMHTs (including psychology), was 126 days. At the time of our previous inspection, the average waiting time between referral and treatment was 133 days. In December 2025, average waiting time between referral and treatment for the 3 CMHTs visited (including psychology) had reduced to 110 days. The wating times for CMHTs (excluding psychology), was 41 days (against the 126 day target) between referral and treatment.

At the time of our previous inspection, the average wait for psychology across all CMHTs was 351 days. In December 2025, the average waiting time (between referral and treatment) for psychology was 110 (equivalent to a 69% reduction), demonstrating significant improvement against the 126‑day target. The highest waiting time (182 days) was for City West CMHT, and the lowest waiting time (69 days) was for East Leicestershire CMHT.

Whist there was variation in waiting times across the 3 CMHTs, waiting times had reduced significantly. The provider identified factors contributing to longer waits and had implemented actions including recruitment and retention initiatives, the introduction of a clinical network, and new job plans aligned to national British Psychological Society (BPS) guidance.

The CMHT standard operating procedure stated that the expected caseload for a full‑time care coordinator (nurse or occupational therapist) was 25, adjusted for part‑time staff. Most practitioners held caseloads which, when adjusted for whole-time equivalent (WTE), fell between 20 and 29 cases per WTE.

Provider data showed variation in allocation levels between localities. When adjusted for WTE, City East CMHT had the highest non‑medical multidisciplinary team allocation intensity (15 cases per WTE), followed by Northwest Leicestershire (12) and East Leicestershire (11). City East also had the highest community psychiatric nurse caseload intensity (21 per WTE) and peer support worker allocation (28 per WTE). East Leicestershire had higher occupational therapy and healthcare assistant allocation per WTE, while Northwest Leicestershire had the highest psychology allocation per WTE.

Consultant psychiatrist caseloads were substantially higher than other MDT roles across all teams. The average consultant psychiatrist caseload was 539 patients, ranging from 651 in City East CMHT to 515 in Northwest Leicestershire CMHT. Consultant caseloads were supported by specialty doctors and rotating resident doctors.

Average psychologist caseloads also varied. City East CMHT had an average caseload of 10.5 patients, Northwest Leicestershire CMHT 15.5 patients, and East Leicestershire CMHT 8 patients. Leaders monitored caseloads to support safe and effective practice and inform workforce planning and prioritisation.

The provider reported that 65 patients across the 3 CMHTs had not had contact with outpatient services in the previous 12 months. Of these, 56 had either cancelled or did not attend appointments. Of the remaining 9 patients, 4 were being seen regularly by a community psychiatric nurse and discussed at MDT meetings, and had been scheduled for recall within 12 months, as this was considered clinically appropriate. There were no patients in the PIER team who had not been seen within the previous 12 months.

The PIER team standard operating procedure referenced Royal College of Psychiatrists’ guidance, which states that caseloads for a WTE mental health practitioner should not exceed 15. Average caseloads were 19 for band 6 nurses, 13 for band 7 nurses and 4 for nursing associates. At the time of inspection, 2 staff were on maternity leave and there was 1 vacancy. A band 6 nurse had recently been recruited and was completing induction, and agency staff were used to maintain safe staffing levels. Although some caseloads were above the expected level of 15, they remained below the higher thresholds referenced in the updated statement of purpose (January 2026).

The adult mental health directorate worked collaboratively with system partners through a mental health collaborative and used a health inequalities dashboard to monitor access and non‑attendance by demographic group. This work had led to targeted projects focused on supporting people experiencing homelessness and those living in the most deprived areas.

Staff made reasonable adjustments to support access for patients, including ensuring services were accessible for people with mobility needs. There was adequate medical cover across teams, and the number of permanent consultants had increased, with 8 fewer locum psychiatrists in post compared with the previous inspection.

Staff ensured that patients had access to appropriate post‑discharge support, including section 117 aftercare, community mental health services and crisis services. Discharge planning was collaborative and involved patients in decision‑making. Discharge plans included relapse prevention planning and the provision of relevant information and signposting to community services.

Staff and leaders actively listened to information about patients who were most likely to experience inequality in access, experience or outcomes, and tailored care, support and treatment in response.

Staff within the service and the wider organisation promoted a culture in which patients felt empowered to share their views. Patients were involved in service development, and mechanisms were in place for patients and carers to provide feedback on their experiences of care.

The provider had undertaken equality impact assessments of policies and procedures to ensure they did not disadvantage vulnerable patients or those with protected characteristics under the Equality Act. This helped to identify and mitigate potential inequalities in the design and delivery of services.

Staff were trained in equality, diversity, inclusion and human rights. The provider had mandatory training in equality, diversity and inclusion, and training completion rates across three of the four teams inspected were 100%, providing assurance that staff were equipped to support inclusive and equitable care.

The provider had several initiatives in place to address health inequalities in partnership with system organisations. This included a health inequalities strategy, a supporting framework and a dedicated health inequalities programme aimed at understanding and addressing inequalities in access, experience and outcomes. Staff used national health inequalities tools to identify differences in life expectancy, mortality and outcomes, informing targeted actions with partners.

Patients were supported to plan for important life changes, giving them sufficient time to make informed decisions about their future, including planning at the end of life where appropriate.

Staff developed personalised care plans that reflected patients’ individual needs, wishes and feelings. Care plans were written in the first person to reflect the patient’s voice, and records demonstrated clear evidence of patients’ involvement in their care planning.

Patients we spoke with told us they were involved in discussions about their future care and discharge planning. Where appropriate, carers were also involved in the care planning process to support continuity and shared understanding.

Staff regularly reviewed patients’ longer‑term plans, including treatment goals and objectives for discharge or transfer of care to another service when appropriate. This helped ensure care remained responsive to changing needs.

There were effective processes in place to support the planning and delivery of discharge or transfer of care. Staff worked collaboratively with other professionals and services to ensure patients could access the ongoing support they needed.

Staff ensured that all relevant healthcare professionals and partner organisations were involved in planning care for patients with complex needs. All referrals were discussed at multidisciplinary team meetings to agree the most appropriate care pathway and to identify the professional group best placed to meet each patient’s needs.