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

This means we looked for evidence that patients were protected from abuse and avoidable harm.

At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant patients were safe and protected from avoidable harm.

All environments were safe, clean, well equipped, well furnished, well maintained and fit for purpose. Staff assessed and managed risks to patients and themselves well. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. The service used systems and processes to safely prescribe, administer, record and when required store medicines. The service managed patient safety incidents well.

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 had a shared vision, strategy and culture that was underpinned by transparency, equity, equality and human rights, diversity and inclusion, engagement, and a clear understanding of the challenges faced by patients and their communities.

Staff understood the provider’s vision and values and were able to describe how these were applied in their day‑to‑day work. Staff told us they had opportunities to contribute to discussions about service strategy, particularly where services were changing or developing.

The provider’s senior leadership team had communicated the vision and values effectively to frontline staff. This aligned with the trust’s shared vision, “Together we thrive, building compassionate care and wellbeing for all”. The THRIVE strategy (a joint strategy with Northamptonshire Healthcare NHS Trust), was aimed at improving health outcomes and wellbeing for local communities. The THRIVE strategic priorities included making a difference together”, which guided the trust in its day to day mission and planning.

Staff demonstrated an understanding of how high‑quality care was delivered within available resources and could explain how they balanced quality, safety and efficiency within the budgets available to them.

The service worked collaboratively with patients and healthcare partners to establish and maintain safe systems of care, in which safety was actively managed and monitored. Staff worked effectively with relevant health, social care and voluntary services to ensure patients experienced continuity of safe care, both within the service and following discharge.

The service’s referral and admission processes ensured that essential information about patients was received and reviewed to determine whether their needs could be safely met. Since the last inspection, the provider had reviewed referral and assessment processes across all teams to strengthen consistency and ensure people were directed to the most appropriate services.

All referrals were received and screened through a single point of access. Referrals were discussed at multidisciplinary meetings attended by doctors, nurses, occupational therapists, psychologists and community connectors. The multidisciplinary team considered each person’s needs and identified which professional was best placed to provide care. The provider had introduced pathway assessments to support decision‑making and ensure patients were allocated to appropriate care pathways and services.

Community connectors played a key role in supporting safe pathways of care. Their role included signposting patients to appropriate community‑based services and maintaining contact with patients while they awaited assessment and throughout the assessment process. Community connectors supported patients to access relevant voluntary and statutory services, which helped reduce the risk of deterioration and supported continuity of care.

The service worked collaboratively with patients and healthcare partners to understand what being safe meant to them and how best to achieve this. The service focused on improving patients’ lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns promptly and appropriately.

Staff were trained in safeguarding and understood how to recognise and respond to safeguarding concerns. They knew how to make safeguarding alerts and did so when appropriate. Compliance with safeguarding adults training was 100% at level 1, over 99% at level 2, and 98% at level 3. Compliance with safeguarding children training was over 99% at levels 1 and 2, and 100% at level 3.

Staff were able to give clear examples of how they protected patients from harassment and discrimination, including those with protected characteristics under the Equality Act. Staff demonstrated a good understanding of how to identify adults and children at risk of, or experiencing, significant harm. They described effective partnership working with other agencies to safeguard patients.

Between July and December 2025, the provider made 42 safeguarding referrals. The highest number of referrals (23) were made by the psychosis intervention and early recovery (PIER) team, while the lowest number (2) were made by the Northwest Leicestershire Community Mental Health Team (CMHT). Of the referrals made, 31 were to adult social care, 3 to children’s social care, 4 to the police, and 4 related to domestic abuse, stalking and honour‑based violence (DASH).

Mental Capacity Act

Staff had received training in the Mental Capacity Act (MCA). Completion rates were 100% for staff in City East, East and Northwest Leicestershire Community Mental Health Teams (CMHTs), and for doctors across all four teams. The lowest completion rate was 96.9% within the psychosis intervention and early recovery (PIER) team.

Staff demonstrated a good understanding of the Mental Capacity Act, particularly the five statutory principles. The provider had a policy in place relating to the Mental Capacity Act, including deprivation of liberty safeguards. Staff were aware of the policy, had access to it, and knew where to seek advice within the organisation regarding the Mental Capacity Act and deprivation of liberty safeguards.

Staff took all practicable steps to support patients to make their own decisions. Where patients may have lacked capacity, staff appropriately assessed and recorded capacity on a decision‑specific basis, particularly in relation to significant decisions. Where patients lacked capacity, staff made decisions in their best interests, taking account of the person’s wishes, feelings, culture and history.

The service had effective arrangements in place to monitor compliance with the Mental Capacity Act. Staff audited the application of the Act and acted in response to learning identified through audit activity.

The service worked with patients to understand and manage risks through a holistic approach. Staff assessed and managed risks to patients and themselves effectively and followed best practice in anticipating, de‑escalating and managing challenging behaviour. Care was delivered in a way that was safe and supportive, while enabling patients to do the things that mattered to them.

During our inspection, we reviewed 17 risk assessments and risk management plans. Staff completed risk assessments for each patient at the point of assessment using a recognised tool and reviewed these regularly, including following any incident. Staff were aware of individual risks and took appropriate action to prevent or reduce harm.

The provider shared data which showed that, over the 6 month period from July to December 2025, there had been no use of restrictive practices, including physical restraint or rapid tranquillisation, across the 4 community teams inspected.

Staff involved patients in the development and review of their care plans and risk assessments, which staff described as a collaborative process. Care plans included clear goals with review dates and incorporated patient promise indicators (previously known as patient‑reported outcome measures, PROMs). Care records demonstrated evidence of patients’ involvement and included their views about presenting needs and strengths. Patients had access to a copy of their care plan.

The provider undertook monthly audits of care records. For December 2025 and January 2026, compliance for having a risk assessment in place and in date was 100%. The lowest compliance rate for risk assessments being in place was 87.5% in September 2025, and the lowest rate for risk assessments being in date was 66.7% in October 2025. The provider used audit findings to drive improvement.

Staff communicated effectively with patients to ensure they understood their care and treatment. Where appropriate, staff used a range of methods to support patients with communication needs, including easy‑read information, information available in patients’ preferred languages, and access to interpreters. Staff enabled patients to provide feedback on the service they received, including through patient surveys.

Staff ensured that patients were able to access advocacy services when required.

The service identified and controlled potential risks within the care environment and ensured that equipment, facilities and technology supported the delivery of safe care.

During the inspection, we reviewed the reception and toilet areas at the Northwest Leicestershire Community Mental Health Team (CMHT). At the time of the previous inspection, these areas were co‑located with child and adolescent mental health services (CAMHS). We found that this was no longer the case, as the base was no longer shared with CAMHS.

The provider had arrangements in place to assess and manage environmental risks. Staff completed regular environmental risk assessments using a standardised checklist, which covered relevant trust and national requirements, including the Management of Health and Safety at Work Regulations 1999. Staff had also completed ligature risk assessments across all areas and implemented appropriate measures to mitigate identified risks. However, we identified 1 ligature point that had not been included in the risk assessment. This was raised with the provider during the inspection and was addressed immediately. The ligature point identified was boxed in on 28 January 2026.

The provider had a lone working process in place, which staff followed. Staff had easy access to alarms within team bases, and these were checked weekly to ensure they were functioning correctly.

The provider had an estates strategy in place that considered the future needs of community mental health services, which continue to expand. The strategy aimed to ensure services were community‑based, reducing the stigma associated with returning to hospital sites following discharge and supporting recovery. Plans were in place to meet these identified needs, including the planned relocation of the Northwest Leicestershire CMHT.

The service ensured there were sufficient numbers of qualified, skilled and experienced staff who received effective support, supervision and development. Staff worked collaboratively to provide safe care that met patients’ individual needs.

Managers had calculated the number and skill mix of staff required to deliver the service safely. This included doctors, allied health professionals, professional scientific and technical staff, nurses, healthcare assistants and administrative staff. The total staffing establishment across the community mental health teams was 122 whole‑time equivalents (WTE).

As of December 2025, the service had 18 WTE vacancies across the 4 community teams visited, representing a vacancy rate of 15%. The highest number of vacancies 10.25 were for ‘additional clinical services non-registered clinical staff (e.g. HCAs, therapy support, peer support workers, community connectors). In addition, the service had 6.4 WTE vacancies for community nurses (covered by bank and agency). The remaining vacancies were for administrative staff. Vacancy rates for Northwest Leicestershire and East Leicestershire were not reported in the previous inspection report. However, at the time of the last inspection, the vacancy rate for the City East and psychosis intervention and early recovery (PIER) teams was 23%, representing a reduction of 8%.

When required, managers used agency and bank staff to maintain safe staffing levels. Between July and December 2025, an average of 122 shifts per month were covered by agency staff. The highest number of agency shifts (145) was in July 2025, and the lowest number (108) was in October 2025. During the same period, an average of 55 shifts per month were covered by bank staff, with the highest number (63) in December 2025 and the lowest number (45) in September 2025. The trust reported that there were no unfilled shifts during the same 6 month period. Agency and bank staff received an induction and were familiar with the service.

The average sickness absence rate between July and December 2025 was 5%, which was below the trust target of 5.6%. The highest sickness rate by team was 10% in the Northwest Leicestershire team in October 2025, and the lowest was zero in the East Leicestershire team in December 2025. The average staff turnover rate across the community teams was 7.21%, which was below the trust target of 10%.

The provider had a mandatory and role‑essential training policy in place, which set out training requirements by staff role, including agency and bank staff and volunteers. Staff had completed and were up to date with mandatory training. The trust’s target compliance level was 85% or above for mandatory training, with a higher target of 95% for data security awareness. All 4 teams inspected met or exceeded these targets, achieving 100% compliance for mandatory training. Training was appropriate to the needs of the patient groups using the service.

The service assessed and managed the risk of infection effectively, took action to detect and control the spread of infection, and shared concerns promptly with appropriate agencies when required.

Staff maintained equipment appropriately and ensured it was kept clean. Where applicable, cleaning stickers were visible and in date, providing assurance that equipment had been cleaned and checked regularly.

The premises were clean, well maintained, and furnished to a good standard. Staff were required to complete infection prevention and control (IPC) training, and all 4 teams had achieved 100% compliance. The main reception area, waiting rooms and consultation rooms were clean and well maintained.

Patients who used services and visitors were required to sign in and out at the main reception. Staff adhered to IPC principles, including effective hand hygiene. Handwashing facilities and clear hand‑hygiene posters were available throughout the service, including in toilet areas. During the inspection, staff were observed to be following IPC procedures.

The service ensured that medicines and treatments were managed safely and met patients’ needs, capacities and preferences. Patients were involved in planning their care, including when changes to medicines occurred, and were fully informed of any side effects of their medicines.

Staff followed good practice in medicines management, including the safe transport, storage, dispensing, administration, reconciliation, recording and disposal of medicines. Where required, staff also followed appropriate processes for the use of covert medication. Medicines management practices were in line with national guidance.

Most patients had their medicines delivered directly to them. For patients who were unable to order or collect their medicines, staff supported this process. Medicines were transported using secure medicines bags to ensure safety.

All medicines‑related incidents were reported electronically and automatically escalated to the head of pharmacy. The provider shared data showing that, between July and December 2025, 6 medicine related incidents were reported. Of these, 3 were graded as low harm and 3 as no harm. Documentation demonstrated that appropriate actions were taken in response to each incident and that discussions had taken place with patients who used services.

The adult community mental health service operated dedicated clozapine clinics and olanzapine depot clinics. Clozapine is an antipsychotic medicine requiring strict blood monitoring, and olanzapine is a long‑acting antipsychotic injection with recognised health risks following administration. Patients receiving these medicines were monitored appropriately in line with trust guidance and national standards.

Staff regularly reviewed the effects of medicines on patients’ physical health, in line with National Institute for Health and Care Excellence ( NICE) guidance, particularly where patients were prescribed high‑dose antipsychotic medication. The trust had shared‑care agreements in place for most mental health medicines, which clearly outlined responsibilities for physical health and cardiometabolic monitoring. Shared‑care arrangements enabled patients to access medicines closer to home while ensuring appropriate ongoing monitoring.

The trust employed a linked mental health facilitator who worked within GP practices. This role supported collaborative working between community mental health teams (CMHTs) and GPs and helped ensure that people with severe mental illness received core physical health checks in line with national guidance.

The provider undertook quarterly medicines management audits against 11 standards relating to the safe management of medicines. Compliance across teams was 100%, except for the Northwest Leicestershire team, which achieved 90% compliance. This related to a medicines storage cupboard that did not meet British safety standards. The trust told us that plans were in place to replace the cupboard, and the local acute trust’s medicines management code had been updated to reflect the requirement for metal medicines cabinets in line with British standards.