- SERVICE PROVIDER
Leicestershire Partnership NHS Trust
This is an organisation that runs the health and social care services we inspect
Assessment report published 27 August 2026
Contents
Ratings - Wards for people with learning disabilities or autism
Our view of the service
Leicestershire Partnership NHS Trust provides mental health, learning disability and community health services across Leicester, Leicestershire and Rutland. The trust serves a population of approximately one million people, has a budget in excess of £250 million and employs over 5,500 staff in a wide variety of roles. The trust works alongside schools, local hospitals, GP practices, social services and other local authority departments, including housing and education. It also works with voluntary organisations and local community groups to help ensure people’s needs are met and that care is delivered to a high standard.
We inspected the Agnes unit, at Leicestershire Partnership NHS Trust, on 5 and 6 May 2026. At the Agnes unit, the trust provided assessment and treatment for adults with a learning disability and/or autism who have mental health needs, behaviours that challenge, or associated risks. Care is delivered by a multidisciplinary team and is underpinned by positive behaviour support. The Agnes unit for people with learning disabilities or autism is part of the families, young people, children’s and learning disability and autism services directorate.At the time of our inspection, the unit had 12 beds.
This was an unannounced inspection, carried out as part of our planned inspection programme, which included an out of hours visit. During our inspection we spoke with 22 staff members, attended a shift handover, safety huddles and reviewed 3 clinical records. In addition, we spoke with 2 of the 3 patients on the ward.
People may be admitted informally or detained under the Mental Health Act 1983. Where people are informal, a deprivation of liberty assessment is completed to ensure care is delivered within the appropriate legal framework.
The most recent previous inspection of the trust’s wards for people with a learning disability or autism took place between 25 May and 6 July 2021. This inspection focused on the safe and well‑led key lines of enquiry only. The service delivered safe, effective and person-centred care, supported by strong multidisciplinary working and governance systems. However, there were areas for improvement, including workforce wellbeing due to ongoing incidents of violence and aggression, variability in record keeping, and ensuring Mental Capacity Act assessments were consistently decision-specific and up to date The ratings from this inspection were Safe and Well Led: Requires Improvement.
An assessment has been undertaken of a specialist service that is used by autistic people or people with a learning disability. We have assessed the service against ‘Right support, right care, right culture’ guidance to make judgements about whether the service guaranteed people with a learning disability and autistic people respect, equality, dignity, choices, independence and good access to local communities that most people take for granted.
Mental Health Act and Mental Capacity Act Compliance Summary
Staff were trained in and had a good understanding of the Mental Health Act (MHA), the Code of Practice and the guiding principles. As of May 2026, 90.5% of nursing staff and allied head professionals (AHPs), and 100% of doctors were up to date with their Mental Health Act training. As of May 2026, 99% of staff, were up to date with their Mental Capacity Act training. A monthly audit was undertaken in relation to the application of requirements under the MHA to ensure that patients had been read their rights and that the MHA paperwork was in order and up to date. The audit results showed that no actions were required, except for July 2025 and February 2026, when staff were required to review a person’s rights (under section 132 MHA) for one person on the ward.
The provider completed monthly audits of Mental Capacity Act (MCA) documentation as part of the learning disability clinical record-keeping audit. This included checking whether each person’s capacity had been assessed. Between May 2025 and April 2026, overall
Staff had easy access to administrative support and legal advice on implementation of the Mental Health Act and its Code of Practice. Staff knew who their Mental Health Act administrators were.
Staff had easy access to local Mental Health Act policies and procedures and to the Code of Practice. People had easy access to information about independent mental health advocacy. Staff explained to people their rights under the Mental Health Act in a way that they could understand, repeated it as required and recorded they had done it.
Staff requested an opinion from a second opinion appointed doctor when necessary. Staff stored copies of people’s detention papers and associated records (for example, Section 17 leave forms) correctly, so they were available to all staff who needed access to them.
Staff carried out regular audits to ensure the Mental Health Act was being applied correctly and there was evidence of learning from those audits. The average percentage audit results between May 01, 2025, and end of April 2026, was 81.87%. The lowest audit results were 88.30%, in May 2025 and 64.70% in November 2025. The highest audit results were 92.2% in June 2025 and 92.7% in July 2025. The trust had developed an action plan to address all areas for improvement. All actions have been completed.
People's experience of this service
At the time of our inspection, there were 3 people at the Agnes unit. We were able to speak to 2 out of the 3 people. We also spoke with one carer and an assisted living manager.
The carer told us that staff were aware of the person’s needs and told us that it “was like a different planet, a second chance of life, they understood and knew how to provide relevant care to autistic nonverbal people with challenging behaviour. They had psychology, speech and language, dieticians and most important is therapy team. They were amazing and gave excellent care. Staff were very polite and respectful. Staff were caring and interested in wellbeing. Compared to previous care the care is excellent. Agnes unit gave him a second chance of life. The Agnes unit took him on, and massive improvements made for his recovery”.
All feedback received was positive. One person told us that they had experienced difficulties at their last placement, however was “finding it fine” on the unit adding that the “like it here. I was as happy as Larry yesterday; I went to see the foal up on the farm and fed it a carrot”. The person added that they were able to get out often, and that they had 3 walks a day. Another person told us that they didn’t need to talk to the CQC adding that they “just want to sleep”.