Leicestershire Partnership NHS Trust

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

This means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

At our last assessment in 2019, we rated this key question Good. At this assessment the rating has remained Good.

Staff completed comprehensive assessments of people's physical and mental health needs and developed personalised care plans that were regularly reviewed and updated. People received evidence-based care and treatment from a multidisciplinary team with the skills and expertise to meet their needs. Staff worked effectively with families, carers and partner agencies to ensure care was coordinated and continuity of care was maintained, including during admissions and discharge. The service promoted people's physical health and wellbeing and supported people to access appropriate healthcare. Staff understood and fulfilled their responsibilities under the Mental Health Act 1983 and Mental Health Act Code of Practice.

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.

We scored the service as 3. The evidence showed a good standard. The service made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

During inspection we reviewed the care records of all 3 people on the unit. Staff had completed a comprehensive mental health assessment of the people in a timely manner at, or soon after, admission.

Staff assessed people’s physical health needs in a timely manner after admission. People had access to a general practitioner (GP), who was the physical health lead on the unit.

All people had detailed physical health assessments in place, including evidence of annual health checks. Annual health checks are preventative physical and mental check-ups for individuals with Severe Mental Illness (SMI) or learning disabilities. Their purpose is to spot undiagnosed illnesses early, monitor the physical side-effects of mental health medications, reduce premature mortality, and create a personal Health Action Plan.

Staff worked closely with people and other agencies (including the LDA collaborative) to understand the needs of the people and to ensure the needs of patients are understood and met. This was achieved via the use of people centred care plans and positive behavioural support plans (PBS).

Staff used therapeutic observations to maintain people’s safety, and recorded physical health observations such as vital signs, observations and generated NEWS2 scores, on an application of the electronic health record. In addition, visualisation screens have been introduced at the Agnes Unit to support real-time monitoring of people’s’ observations. The visualisation screens provide observation of people on the unit, offering a clear overview of the person’s current status, highlighting any overdue observations allowing staff to review trends and help inform interventions. The trust conducted monthly audits regarding people’s observation levels. The average compliance April 2025 to the end of March 2026, was 100%.

Staff had assisted people in the development of health action plans. A health action plan is a personalised document that outlines an individual’s specific health needs, goals and the actionable steps required to maintain or improve their wellbeing. The health action plan, completed for each health issue, included details on known triggers, during and after an episode, and treatment.

Staff had developed care plans that met the needs identified during assessment. Care plans were personalised, holistic and recovery oriented. Staff updated care plans when necessary. People had access to a range of physical healthcare and therapy support including nursing, medical, occupational therapy, speech and language therapy, physiotherapy, and dietician. Services provided people with easy-to-read leaflets, which enabled people to understand the service and what would happen to them.

Staff communicated with people in ways that supported their understanding of care and treatment and made appropriate adjustments for people with communication difficulties. All people on the unit had communication passports in place to guide staff on how best to communicate effectively with them.

Staff had involved people in care planning and risk assessments. Care plans were completed for each new person within 2 weeks of admission, as detailed in the Agnes unit standard operating procedure. People had access to easy‑read documentation and “my care plan”, which ensured that people were fully involved in decision‑making. The ward provided accessible care plans and resources to meet each person’s specific needs.

Staff had also completed positive behavioural support (PBS) plans with people. These plans set out people’s needs, triggers, early warning signs, proactive support strategies and preferred communication approaches. The PBS plans also included details regarding recommended de-escalation techniques and agreed responses to crisis situations, with the aim of reducing distress, improving quality of life and minimising restrictive interventions.

We scored the service as 3. The provider planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards.

Staff provided a range of care and treatment interventions suitable for the people group. The interventions were those recommended by, and were delivered in line with, guidance from the National Institute for Health and Care Excellence (NICE). This included medication, monitoring of people’s progress, psychological therapies, activities, training and work opportunities intended to help people acquire living skills.

The trust shared a copy of the unit’s standard operating procedure (SOP), which set out the unit’s values and principles. These had been developed in line with the NHS Mental Health National Service Framework (1999) and the quality network for inpatient learning disability services (QNLD) standards.

Staff ensured that people had good access to physical healthcare, including specialist input when needed. All people received a holistic physical health review within the first 2 weeks of admission. People also received a full physical examination by a doctor on admission, alongside baseline health observations.

Staff recorded examination outcomes in people’s electronic health records. If a person refused the examination or was too distressed for it to be completed, staff repeated it or handed it over to another doctor until the observations had been completed.

The trust were key members of the learning disability and autism (LDA) collaborative health inequalities programme, an NHS partnership working to reduce health inequalities for autistic people and those with learning disabilities. The collaborative unite healthcare providers, local councils, and experts by experience to ensure equal access to care. This programme has delivered coordinated, evidence-based health promotion, directly addressing inequalities affecting people with learning disabilities. The programme has resulted in significant progress in relation to bowel screening, with reasonable adjustments, easy-read materials and targeted practitioner support, early cancer diagnosis and screening, including bowel, cervical and lung cancer. For cervical screening, the programme has addressed longstanding inequalities through accessible education, myth busting resources, workforce training and the development of specialist LD cervical screening clinics, alongside personalised preparation, and targeted individual support for those experiencing anxiety or barriers to access.

Staff assessed and met people’s needs for food, drink, nutrition and hydration, including specialist support where needed. Staff had completed nutritional monitoring tools for each person, which staff updated monthly. Staff also recorded people’s food and fluid intake daily in order to ensure that people were remaining well fed and hydrated.

Staff participated in a range clinical audits, benchmarking and quality improvement initiatives. The trust shared the results of several audits undertaken at ward level. For example, managers conducted a monthly audit of physical healthcare. This audit examined whether physical health observations had been completed, whether the relevant forms and care plans were in place, and whether physical health needs were reflected in care plans and being implemented. The ward scored 100% in each month from April 2025 to April 2026. Staff also completed a mattress condition checklist audit, which had been scored 100% for each of the 12 months May 2025 to end of April 2026.

Leaders also undertook a monthly record keeping audit. The overall average audit result between May 2025 and April 2026 was 80%, indicating a variability in record keeping. Actions had been identified to address these gaps. The highest score (95.5%) was in August 2025, and the lowest score (70%) was in November 2025. The clinical record keeping audits results were reviewed monthly through the inpatient assurance meeting and actions had been developed to address the identified gaps.

The team included or had access to the full range of specialists required to meet the needs of people in the service Staff were experienced and qualified and had the right skills and knowledge to meet the needs of the people group. Managers identified the learning needs of staff and provided them with opportunities to develop their skills and knowledge. The provider submitted information in relation to specialist non mandatory training. Additional training included positive behavioural support (PBS) training. Staff had also attended sensory awareness workshop and getting communication right.

Managers provided all new staff with appropriate induction, including bank and agency staff. Managers provided staff with supervision (meetings to discuss case management, to reflect on and learn from practice, and for personal support and professional development) and appraisal of their work performance. Staff were provided with both clinical and managerial supervision. The compliance rate for both clinical and managerial supervision was 90.3% (against a trust target of 85%). Managers ensured that staff had access to regular team meetings.

The percentage of staff that had had an appraisal in the last 12 months was 88.3% (against a trust target of 80%).

Managers dealt with poor staff performance promptly and effectively.

We scored the service as 3. The provider worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

Staff held regular and effective multidisciplinary meetings. Staff shared information about people effectively at shift handovers. Handover meetings were minuted and available to all staff.

During our inspection, we observed handover between day and night staff. This included full information about people, including details of care, risk management and positive behavioural support plans. We also observed the daily safety huddle, which followed a set agenda. Staff discussed physical health observations, incidents, therapeutic activities, daily recordings, including food and fluid intake and NEWS2, and any concerns.

The unit held daily safety huddles Tuesday to Friday. All on duty clinicians attended the meeting, which was chaired by medical staff. The aim of the safety huddle is to ensure timely clinical review of the last 24 hours and that a plan of care is agreed. The huddle confirms staffing allocation and identifies any escalations. Staff recorded the outcome of all clinical discussions from the huddle in the person’s clinical records. Weekend safety huddles were led by on-call LD Consultant and shift leader.

The team had effective working relationships, including good handovers, with other relevant teams within the organisation. Links with community teams were embedded in everyday practice including the LD crisis response and intensive support team.

The team also had effective working relationships with teams outside the organisation (for example the local authority, integrated care board and commissioners). The trust had extensive working relationships with a range of external providers including University Hospitals of Leicester, and the LDA collaborative. This is led by Leicestershire Partnership NHS Trust and includes all 3 local authorities (Leicestershire County, Leicester City Rutland), the Integrated care board (ICB).

We scored the service as 3. The evidence showed a good standard. The service supported people to manage their health and wellbeing to maximise their independence, choice and control. The service supported people to live healthier lives and where possible, reduce their future needs for care and support.

Staff supported people to live healthier lives. This included healthy eating advice, managing cardiovascular risks and screening for cancer. Staff used a healthy living toolkit, which was designed for providers who support individuals with learning disability. It is a comprehensive resource to promote healthier lifestyles, with a focus on nutrition, hydration, and physical activity. The toolkit addresses any health concerns and disparities often faced by individuals with learning disabilities to support the delivery of equitable and person-centred care.

The trust was one of two systems nationally selected to work alongside NHS England on a pilot to test the feasibility of developing a combined health check for people with a learning disability, autistic people and people with serious mental illness. The trust’s completion rates were on track to exceed the planned target and had consistently exceeded the quarterly targets in its plan. The pilot required the trust to work with national, regional and local leaders, clinical advisers, information management and technology specialists, commissioners, lived experience leads and evaluation leads to establish training, procedural guidance, IT systems, reporting processes and contractual arrangements

Staff supported people with meal preparation, and measured people’s ability to plan meals over time. Staff educated people via use of easy-to-read information and educational programmes. Ward activities helped promote a healthy lifestyle for people, for example staff took people out of the ward visiting a local farm, sports activities and cooking healthy meals.

Staff recorded peoples’ vital signs, including blood pressure, pulse, respiration and oxygen saturation, each day. Leaders had undertaken a monthly audit of physical health observations. The audit examined if physical health observations had been recorded on the electronic health record, and if all physical health needs had been reflected in the person’s care plan. The audit results April 2025 to end of March 2026 was 100% for all 3 questions.

Staff recorded people’s weight and BMI, recognising the increased risk of weight-related concerns for people with long-term conditions. Staff offered people advice about nutrition and healthy living.

Staff provided people with an easy-to-read healthy living toolkit (developed by the Leicester, Leicestershire and Rutland learning disability and autism collaborative), which aimed to improve health outcomes for people with a learning disability and autism. The toolkit provided people with advice on eating and living well including information regarding healthy weight, physical activity, healthy lifestyle and physical activity opportunities.

We scored the service as 3. The evidence showed a good standard. The service routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves.

Staff used recognised rating scales to assess and record severity and outcomes. Staff used the health of the nation outcome scale for people with learning disabilities (HoNOS-LD), as the main evidence-based outcome measures. Staff measured outcomes on people’s admission, at three-monthly intervals, and at point of discharge. This allowed for consistent assessment of wellbeing, clinical presentation, risk, and behaviour overtime. Staff used outcome measures to support clinical decision-making within weekly multidisciplinary team (MDT) meetings and to support the reviews and updates of people care plans.

The Occupational Therapy (OT) team use the validated model of human occupation exploratory level outcome ratings assessment tool as an outcome measure. This enabled staff to track changes in occupational participation over time; focusing on motivation, pattern of occupation, communication/interaction skills, process skills, motor skills and environment. At the time of inspection, the OT team were undertaking specific training in relation to the model of creative ability, which will help staff assess and measure a person’s level of creative ability as it develops over time.

We scored the service as 3. The evidence showed a good standard. The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

Staff understood the Mental Capacity Act (MCA) 2005 and applied its principles. Staff had completed MCA training and knew where to access policies and advice.

When people lacked capacity, staff made decisions in their best interests, recognising the importance of the person’s wishes, feelings, culture and history. During our inspection we saw an example where a best interest assessment had been undertaken, for access to urgent physical healthcare.

Where people might have impaired capacity, staff carried out assessments in line with the Mental Capacity Act. MCA assessments were decision-specific and carried out on admission, with best-interest decisions recorded in partnership with families. Records showed people’s’ rights were explained in accessible ways. This was ensured by staff using visual aids, easy read information with short sentences and simple pictures. Staff also used people’s communication passports which outlined how the person communicated and understood information best.