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

This means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good.

This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care. Leaders had the skills, knowledge, and experience to perform their roles. Staff knew and understood the provider’s vision and values and how they applied to the work of their team. Staff felt respected, supported, and valued. Governance processes operated effectively, and performance and risk were managed well. Teams had access to the information they needed to provide safe and effective care. Staff collected analysed data about outcomes and performance. They used this to identify improvements.

This service scored 82 (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.

Since 2023, the provider had been undertaking a transformation programme aimed at reducing caseloads and waiting times. As part of this ongoing work, consultants had been allocated dedicated time each week to undertake caseload reviews, supporting oversight, prioritisation and safer care delivery.

In support of the transformation programme, the trust had introduced a neighbourhood mental health team clinical decision‑making flowchart. This supported clinicians and consultants to make safe, consistent decisions, ensuring patients received the most appropriate intervention from the right service at the right time.

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 had inclusive leaders at all levels who understood the context in which care, treatment and support were delivered, and who embodied the culture and values of the organisation. Leaders demonstrated the skills, knowledge, experience and credibility required to lead effectively and did so with integrity, openness and honesty.

Leaders had a good understanding of the services they managed and were able to clearly explain how teams worked together to deliver high‑quality care. We spoke with a range of leaders, from team leads to senior leaders and directors. All leaders we spoke with demonstrated a clear understanding of the services and were fully aware of the concerns identified at the previous inspection. Leaders described how these concerns had been used as a catalyst for meaningful and, in some areas, radical change within the service.

Community mental health teams operated under a matrix leadership model, where responsibility and decision‑making were shared between 2 or more leaders rather than resting with a single hierarchical lead. Leaders were responsible for different but complementary roles and objectives, and staff reported to more than 1 member of the leadership team. Staff told us this approach had increased flexibility, improved collaboration and reduced delays in decision‑making. Staff told us that matrix leadership meant they felt consistently involved and that communication across teams was effective.

Staff worked to a clear accountability framework, which outlined individual roles and responsibilities. Leaders told us that this had improved clarity and consistency, addressing previous gaps in role definition.

Leaders were visible within the service and approachable for both staff and patients. All staff we spoke with knew who their managers were and told us that leaders were accessible and present. Staff consistently reported feeling supported by their leadership teams.

Leadership development opportunities were available across the organisation. The trust offered a range of leadership pathways, including both managerial and clinical development opportunities. Staff told us that leadership pathways were now mandatory and that they had access to further education, including degree‑level and master’s‑level training, supporting succession planning and capability building.

The service fostered a positive and inclusive culture in which patients and staff felt able to speak up and confident that their views would be listened to and acted upon.

Patients and carers had opportunities to provide feedback about the care and support they received in ways that reflected their individual needs. The service made it easy for patients to share feedback and ideas, or to raise concerns and complaints about their care, treatment and support. Staff enabled patients to provide feedback through a range of methods, including patient surveys, and patients were involved in decisions about changes to the service.

Managers and staff had access to feedback from patients, carers and staff. Managers used this information to support learning and improvement. Community mental health teams actively promoted patient involvement and feedback as part of their approach to quality improvement. Patients told us they knew how to raise concerns and that they received responses when they did so, demonstrating that leaders encouraged openness, responsiveness and learning.

The trust had a clear governance framework to support an open, inclusive and compassionate culture. This included a robust Freedom to Speak Up (FTSU) process, which staff could use to raise concerns confidentially. The FTSU team worked collaboratively with system partners, including Leicestershire Partnership NHS Trust and Northamptonshire Healthcare NHS Foundation Trust, to share best practice and deliver a consistent approach across the system. This aligned with the trust’s shared vision, “Together we thrive; building compassionate care and wellbeing for all”, and its mission, “Making a Difference Together”, published in April 2025.

The trust had systems and processes in place to enable staff to provide feedback. Staff told us they felt able to raise concerns with their managers without fear of reprisal and were confident that concerns would be taken seriously and addressed appropriately. At the time of inspection, the trust had 24 FTSU champions in post, with plans to appoint a further six. FTSU champions acted as visible local points of contact and supported the work of the FTSU guardians, helping to promote an open ‘speaking‑up’ culture.

The trust monitored and reviewed FTSU activity to identify themes and trends. There was 69 FTSU contacts raised in quarter 3 of 2025/26. This represented a 45% increase from 38 contacts in the previous quarter. Leaders viewed this increase as positive assurance that staff felt confident to speak up and that the culture supported openness and transparency.

The trust delivered ‘Speak up, listen up, follow up’ training to staff, demonstrating a proactive approach to embedding its values and expectations. Training compliance for quarter 3 (October to November 2025) was 98%, providing assurance that staff were equipped to raise concerns and respond appropriately when concerns were shared.

Leaders reviewed staff feedback at provider level to inform improvement. We reviewed the most recent staff survey (February to April 2024), which showed overall improvement compared with the previous year. Of the 1,087 questions, 82 showed improvement, including patient promise indicators (previously known as patient‑reported outcome measures, PROMs), many of which were above the national average. Staff understood how their work made a difference to patients’ lives and reported feeling supported by their line managers. However, of those staff who reported experiencing discrimination, 5.6% stated this related to their ethnicity. Leaders recognised this as an area requiring continued focus and improvement.

The evidence showed an exceptional standard. The service strongly valued diversity in their workforce. They had an inclusive and fair culture which had improved equality and equity for people who work for them.

The trust demonstrated exceptional leadership and commitment to tackling inequality through its well‑embedded patient and carers’ race equality framework (PCREF) self‑assessment and delivery plan. PCREF was established as a core, trust‑wide transformation programme, focused on addressing the inequalities experienced by racialised, ethnically and culturally diverse communities. Progress was reported to the transformation and quality improvement committee, providing clear board‑level oversight, scrutiny and assurance.

A PCREF Steering Group had been established to oversee delivery and monitor progress. Membership included staff, patients and carers from marginalised communities, alongside system partners and representatives from the voluntary, community and social enterprise (VCSE) sector. This demonstrated inclusive leadership and a strong commitment to co‑production. The group was co‑chaired by a lived‑experience partner, ensuring that patient and carer voices were meaningfully embedded within governance and decision‑making arrangements.

The trust had developed a focused PCREF delivery plan for 2025/26, structured around 4 core components: workforce and cultural awareness; partnership working; co‑production and lived experience; and data quality and insight. PCREF also formed a central component of the trust’s ‘Together Against Racism programme’, sponsored by the director of mental health. This provided strong executive leadership, clear accountability and alignment with the trust’s strategic priorities.

The trust, in partnership with the African heritage alliance, had presented a manifesto to the PCREF Steering Group, setting out commitments identified by communities as priorities for the trust and the wider system. In addition, in April 2025 the trust commenced work with implementing recovery through organisational change (ImROC), building on learning from a PCREF early adopter site through the ‘live well’ Programme. This programme aimed to work with 3 prioritised communities across Leicester, Leicestershire and Rutland who experience barriers to accessing services and poorer socioeconomic and health outcomes, to improve equity and outcomes.

The trust promoted an inclusive and supportive working culture. Flexible working policies and procedures were in place to support staff wellbeing, retention and work‑life balance. Most staff told us they were able to access flexible working arrangements to support caring responsibilities or health needs, and managers made reasonable adjustments to enable staff to carry out their roles.

The trust further strengthened its equality, diversity and inclusion leadership through the appointment of 4 equality, diversity and inclusion (EDI) ambassadors in 2025. These ambassadors were supported to drive the trust’s ‘Together We Thrive’ ambition to build an inclusive workplace where staff felt psychologically safe, valued and protected.

The trust delivered mandatory training for Equality, Diversity and Human Rights. At the time of our inspection, the completion rate for the 4 teams visited was 100%.

Leaders used equality monitoring data to understand workforce diversity and inform improvement. Analysis of equality monitoring data, including religion, sex and sexual orientation, was reviewed annually and presented to the board. This enabled leaders to identify trends, assess impact and agree targeted actions, demonstrating an effective, data‑driven approach to governance, learning and continuous improvement.

The service had clear roles, responsibilities and systems of accountability, supported by effective governance arrangements. These were used to manage and deliver good‑quality, sustainable care, treatment and support. Leaders used reliable information on risk, performance and outcomes to support decision‑making and shared information securely with relevant partners when appropriate.

The mental health directorate had a clear and well‑embedded governance structure, operating on a four‑weekly cycle. This structure reviewed quality and safety, transformation, finance and performance, and people and culture. Reporting arrangements were clearly defined, and information from meetings flowed effectively into the four directorate governance meetings, providing oversight, assurance and accountability.

The directorate had a framework in place that defined what must be discussed at ward, team and directorate‑level meetings. Review of meeting minutes demonstrated that key information, including learning from incidents, complaints and safeguarding alerts, had been consistently shared, discussed and acted upon.

Staff had implemented recommendations arising from reviews of deaths, incidents, complaints and safeguarding alerts at service level. The provider also undertook and participated in a range of local clinical audits, including audits of outpatient record‑keeping, use of outcome measures (DIALOG), and follow‑up of referrals. These audits provided assurance, and staff acted where improvement was required.

Staff understood the arrangements for working collaboratively with other teams within the organisation and with external partners to meet patients’ needs. For example, community mental health team staff worked closely with crisis resolution and home treatment teams and had developed strong neighbourhood‑level partnerships to support joined‑up care.

The mental health directorate had established governance systems to oversee risk, performance and improvement. Directorate‑level meetings covering transformation, quality and safety, finance and performance, and people and culture reviewed the performance of community mental health teams, including the management of risks, issues and service delivery.

Staff maintained and had access to risk registers at both team and directorate level. At the time of inspection, 6 risks were recorded across the community teams visited. These included risks relating to medical vacancies, car parking, temperature control and service demand. All risks had mitigating actions in place, which were reviewed quarterly. Staff knew how to escalate concerns, and risks identified by staff aligned with those recorded on the risk registers.

The provider had business continuity plans in place for each of the 4 teams inspected. Business continuity plans for the 3 CMHTs had been updated since the previous inspection to reflect neighbourhood team arrangements and updated staff contact details. A new business continuity plan was also in place for the PIER team. Plans covered a range of emergency scenarios, including utilities disruption, adverse weather, infectious disease outbreaks and the receipt of suspicious packages.

Staff had access to the equipment and information technology required to carry out their roles. Information technology systems, including the telephone system, functioned effectively and supported the delivery of care.

Team managers had access to timely, accurate and accessible information to support their management roles. This included data on service performance, staffing and patient care, enabling managers to identify risks, monitor performance and drive improvement. Information governance arrangements ensured the confidentiality and security of patient records.

The service clearly understood and fulfilled its duty to collaborate and work in partnership, resulting in services that were well integrated and seamless for patients. Information and learning were shared proactively with partners to support continuous improvement and better outcomes.

Directorate leaders took a lead role in engaging effectively with a wide range of external stakeholders across the system, (including primary care, commissioners and Healthwatch), to improve the broader health of their population and tackle health inequalities. Staff attended regular meetings with primary care and other partner organisations to support effective communication, shared learning and coordinated care. Staff consistently told us that (central to delivering effective and responsive care pathways for patients), was collaborative working with internal and external teams was deeply embedded and outcomes-focused at every level.

Staff and leaders demonstrated sustained relationships within the local system and beyond. Staff and leaders had fostered a culture of trust and respect, enabling dialogue and collaborative problem solving.

There were strong partnership arrangements in place at neighbourhood level. These included mental health cafés and close links with charitable organisations and local community groups. These partnerships helped extend the reach of services, reduced barriers to access and supported patients to remain engaged within their communities.
Community connectors played a pivotal role in linking patients to appropriate community based services and ensuring that patients’ wider needs were met, including physical, psychological and social needs. Patients, staff and local stakeholders were meaningfully involved as equal partners in the design, delivery, and evaluation of services.
Community mental health teams had shared care arrangements in place with primary care, which clearly defined roles and responsibilities for physical healthcare. This supported joined up working and ensured patients’ physical health needs were consistently addressed alongside their mental health care.
Coproduction was embedded in the service culture, with diverse voices actively shaping decisions. Engagement was inclusive, culturally sensitive, non-discriminatory and sustained.
Patients had access to a digital application that provided information about services available at neighbourhood level, supporting informed choice and self direction. The application was a dedicated platform to help patients in Leicestershire to find activities, groups and support services. The application (seen as an important social prescribing tool), also provided advice, physical activity clubs, community groups and therapies. Leaders told us they met with partners monthly to review performance, share learning and adapt services in response to emerging needs.
Leaders also met regularly with members of the provider’s senior leadership team and commissioners to provide feedback and assurance. The trust was in the second year of its ‘THRIVE’ strategy, which was driven by an assurance framework and embedded across community mental health services. All meeting agendas were aligned to the strategy, ensuring it was consistently applied in day to day governance and understood by staff.
Leaders had undertaken joint development sessions with the board and commissioners to strengthen shared understanding of the trust’s vision and values. This supported alignment across the system and reinforced a collaborative approach to improving outcomes for patients and communities.
 

The service focused on continuous learning and improvement across the organisation and the local system. Staff were encouraged to develop creative and flexible approaches to delivering equitable experiences, outcomes and quality of life for patients. The service actively contributed to safe, effective practice and research.

Staff were supported and given time to participate in improvement and innovation activities. This had led to tangible service changes and the introduction of new ways of working. The trust was midway through delivering a comprehensive transformation programme aimed at developing integrated community neighbourhood mental health teams.

As part of this transformation, the provider had introduced a new “front door” process, including the introduction of community connectors, collaborative multidisciplinary meetings and daily huddles. These changes supported more coordinated decision‑making and improved access to appropriate care. The transformation programme also strengthened multidisciplinary team working, including enhanced psychological consultation and a hub‑and‑spoke model. This enabled clinician‑to‑clinician discussions, reducing the need for unnecessary referrals and supporting more timely and appropriate interventions.

Staff and patients had co‑produced a clinical framework to support consistent and person‑centred care. The service had also introduced the outcome measure DIALOG, supporting structured conversations about patients’ needs, experiences and outcomes and enabling learning to inform care planning and service improvement.

Staff had opportunities to participate in research activity. For example, since 2024, the trust had worked in partnership with external organisations (including the National Institute for Health and Care Research (NIHR) Commercial Research Delivery Centre, the local acute trust, the University of Leicester and industry sponsors). The research project aimed to design a multicentre weight‑management prescribing pathway for people living with severe mental illness and overweight or obesity, to explore the role of weight‑loss medications, and to develop a tailored weight‑management pathway for this population.

Staff used quality improvement (QI) methods and demonstrated an understanding of how to apply them in practice. The trust had adopted a QI approach to improve pre‑conception advice for patients with severe mental illness. In addition, the trust was at the early stage of a QI project to develop a consultation model to support mental health teams in adapting care for patients with autism‑related needs.