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 people’s needs.

At our last assessment February 2019, we rated this key question Good. At this assessment the rating has remained Good. Staff managed beds well. A bed was available when a patient needed one. Patients were not moved between wards except for their benefit. Patients did not have to stay in hospital when they were well enough to leave. The design, layout, and furnishings of the ward supported patients’ treatment, privacy and dignity. Staff supported patients in a range of personalised activities including arts and crafts, trips and day outings. Staff also supported people with activities outside the service, such as work, education and family relationships. Staff used a range of methods to listen to and involve people and carers in their care, including co-production. 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.

We scored the service as 3. The evidence showed a good standard. The service made sure people were at the centre of their care and treatment choices and they decided, in partnership with people, how to respond to any relevant changes in people’s needs.

Staff ensured that people were at the centre of their care and treatment choices. They worked in partnership with people and their families and carers, to decide how to respond to any relevant changes in people’s needs. People felt listened to and felt that their views were valued and considered. Staff empowered people to make decisions about their care wherever possible.

Staff provided people with a range of personalised activities, including arts and crafts, trips and day outings. Staff worked with the trust’s charity to arrange visits from musicians, animals and artists, and to provide enhanced sensory resources. Staff also supported people to access education, work opportunities and meaningful activities where these reflected their needs, preferences and goals.

Staff provided person-centred care, which was directed by ongoing multi-disciplinary reviews. We observed people being cared for in a way that was thoughtful and caring. Staff fully engaged the person in their care delivery. Care plans reflected people's physical, emotional, mental and social needs, and care delivery was person centred.

Staff developed activity programmes in collaboration with people, therapy staff and nursing staff. Activities were person centred, and people could choose activities on and off the ward. Staff developed activity programmes, which were provided in easy-read formats, using symbols to support understanding. Staff had also developed easy read details of activities that people liked to do on the pods, which provided further details of the persons’ likes and dislikes.

Care plans were coproduced with people on the unit. They contained strategies to support people in a person-centred way during episodes of distress and when risks were increasing. People had positive behaviour support plans in place which included strategies for managing people’s distress.

Staff empowered people to make decisions about their care wherever possible. People were supported to express choices around meals, activities and daily routines, and staff respected these preferences. Families confirmed that they were engaged in discussions about care and changes to treatment, ensuring decisions reflected both the person’s current needs and their longer-term wishes.

We scored the service as 3. The evidence showed a good standard. The service understood the diverse health and care needs of people and their local communities, so care was joined-up, flexible and supported choice and continuity.

Where appropriate, staff ensured that people had access to education and work opportunities. Staff supported people to maintain contact with their families and carers.

Staff fully involved family and carers in the persons care and treatment. Staff identified and contacted carers within 1 working day of admission and recorded relevant information about carers in people’s care plans and reviewed this regularly.

Staff followed processes to ensure people had agreed to any information shared with carers. Carers were invited to care programme approach (CPA) admission meetings, which took place within 10 days of admission and were attended by the multidisciplinary team. Staff provided carers with weekly telephone updates and reports, invited them to ward rounds, and involved them in discharge planning. All 3 people on the unit had maintained contact with family, carers and friends.

The service understood the diverse health and care needs of the people it supported and worked flexibly to ensure care was joined-up, person-centred and continuous. Staff ensured that care planning was holistic and that individual preferences were respected, so people received care that reflected their wider lives as well as their immediate health needs.

Staff worked collaboratively with community teams and external professionals, including specialist nurses (for example epilepsy and restrictive practice specialists), to manage complex health needs.

Over the last 12 months, there have been 10 care and treatment reviews (CTRs) at the Agnes unit, including 2 independent care (education) and treatment reviews (ICETRs) undertaken by the Care Quality Commission (CQC). These reviews have identified some concerns in relation to physical health needs, personal relationships, future planning, and the review of sensory preferences and triggers. Managers had developed action plans in response to the reviews, with identified leads and timescales for completion.

Staff supported people to access their chosen place of worship within the community.

We scored the service as 3. The evidence showed a good standard. The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

Staff consistently provided accurate, timely and comprehensive information to support safe, transparent care. Staff made notifications to external bodies, including (CQC), the local authority and relevant commissioners whenever required. Notifications submitted to CQC were comprehensive and consistently made within expected timescales. The trust also informed the CQC of patient safety events via the national learn from patient safety events (LFPSE).

Information governance systems included confidentiality of people’s records. The service complied with the Accessible Information Standard. The trust website provided practical information to support staff to produce easy-read information, including access to a member of the trust’s communication team who specialised in information for people using services.

Accessible information standards training was accessed by staff via the trust’s staff training platform. Staff had received additional easy read training and have developed a wealth of accessible resources that were used widely.

The trust was also leading the systemwide implementation for the reasonable adjustment digital flag (built on the commitment of the accessible information standards), to record, share and view details of reasonable adjustments which were needed when people are attending an appointment or staying in hospital.

Locally the unit provided accessible care plans and resources to meet each person’s specific needs. During inspection we viewed copies of accessible care plans, including the ‘my Agnes unit care plan’ and easy read resources. Staff completed the easy read ‘my Agnes unit care plan’ for each new person within 2 weeks of admission.

Staff, along with University Hospitals of Leicester had developed a local hospital passport and accident and emergency (AE) grab sheet with involvement from experts by experience. These documents outlined (in easy read format) key information that professional staff require to ensure the delivery of person-centred care and treatment.

Staff supported people to develop an information booklet in care of any admissions to an acute hospital. This was in easy read format and provided key information including physical history, medicines, how to care for the person, likes and dislikes and discharge arrangements.

Staff had ensured that people could obtain up-to-date information on treatments, local services, people’s rights, and how to raise a concern or make a complaint. Staff provided people with information in easy-read formats for people with a learning disability. Staff ensured easy-read information was displayed clearly.

Staff ensured that, with consent, carers, families and commissioners were regularly updated about people’s progress. Staff invited family and carers to ward rounds/CPA meetings and provided them with weekly updates.

We scored the service as 3. The evidence showed a good standard. The service made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. They involved people in decisions about their care and told them what had changed as a result.

Staff used a range of methods to listen to and involve people and carers in their care, including co-production. Staff also used the patient and carer race equality framework (PCREF). This is an NHS England framework for mental health services, to help identify, understand and reduce racial inequalities in access, experience, outcomes and involvement for people using services and their carers.

Staff had adopted the triangle of care framework to strengthen partnership working between people, carers and staff. The unit had completed a self-assessment against the framework, identifying areas of good practice, achievements to date and areas for further improvement. The trust had invested in lived experience partners, who provided independent advice and assurance about how the service responded to the voices of people and carers.

The service had received no formal complaints or concerns between 01 May 2025 and end of April 2026. During the same period, the service had received 5 compliments. For example, compliments included the following: ‘the staff are incredibly supportive always willing to help. Their dedication to both residents their colleague's created a warm welcoming environment. The culture of kindness teamwork mutual respect made my time here incredibly rewarding’. Further feedback confirmed that ‘communication between staff families is excellent’ ‘The unit is 100% better than anywhere else, the freedom we have when we visit to walk around is lovely’.

People knew how to complain or raise concerns. When people had complained or raised concerns previously, they received feedback. Staff protected people who raised concerns or complaints from discrimination and harassment.

Staff knew how to handle complaints appropriately. Staff received feedback on the outcome of investigation of complaints and acted on the findings.

We scored the service as 3. The evidence showed a good standard. The service made sure that people could access the care, support and treatment they needed when they needed it.

The LDA collaborative outlined the system ambition and vision to demonstrate commitment to the core principles outlined in the Right Support, Right Care, Right Culture statutory guidance. The Unit ensured that the right care was delivered by undertaking comprehensive learning disability and physical health assessments including annual health checks and by ensuring person‑centred care through the involvement of patients, carers, families, and advocates. The trust was one of two national NHS England (NHSE) sites to test a combined health check for people with a Learning Disability, Severe Mental Illness (SMI) and autistic people.

The unit ensured that care promoted independence and successful reintegration into the community. Staff had developed easy‑read documentation and ‘My Care Plan’ to ensure that patients were fully involved in decision‑making and that care was delivered in the least restrictive way by using a positive behaviour support approach.

Staff had ensured the needs of people with mobility issues could be mostly met. For example, staff were able to access mobility aids and equipment when required. The unit was on one level, and the pods were wide enough for wheelchair users.

There was adequate medical cover day and night, a doctor could attend the ward quickly in an emergency and the hospital was within a reasonable travelling distance to the local acute hospital.

Staff ensured people had access to post-discharge care including section 117 aftercare, community mental health services and crisis services. Staff on the unit worked collaboratively with staff in the community and crisis team.

We scored the service as 3. The evidence showed a good standard. Staff and leaders actively listened to information about people who are most likely to experience inequality in experience or outcomes and tailored their care, support and treatment in response to this.

Staff promoted a culture in which the people using the service felt empowered to give their views. Staff told us that they felt valued and that their views were listened to. The trust actively engaged people with lived experience, had developed a “lived experience leadership framework”, and had identified plans for further involvement of people with lived experience.

Staff actively engaged carers in people’s care and treatment. The unit had completed a self-assessment regarding the criteria laid out in the triangle of care, a quality improvement scheme between people, staff, and their carers. To achieve accreditation, the trust was required to commit to continuous improvement in 6 areas (identification, staff training, confidentiality, designated roles, introductions, and support services). As part of the self-assessment, staff have identified where they are doing well, key achievements to date and where they would like to improve.

The trust had undertaken equality impact assessments of their policies and procedures to ensure they did not place vulnerable people or people with protected characteristics at a disadvantage. These reviews were embedded into organisational practice and supported decision-making at service level.

The trust had introduced the Patient and Carer Race Equality Framework (PCREF), a national NHS requirement to help make mental health services fairer by tackling racism. All NHS mental health trusts were required to have PCREF in place by the end of 2024/25. Priorities for this year included focus on workforce and cultural awareness, coproduction and lived experience and partnership working.

We scored the service as 3. The evidence showed a good standard. People were supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

Staff supported people to make decisions about their care and treatment and their future. People were actively involved in the planning of their care. Staff were trained in positive behavioural support (PBS), and all people had a PBS and care plan in place. Care and PBS plans were highly personalised and consistently co‑produced with people and, where appropriate, their families and carers. Each care plan clearly reflected the person’s voice, priorities, wishes, and feelings, including where these differed from wider multidisciplinary views.

Staff had ensured that all relevant healthcare professionals and other relevant bodies were involved in planning the care and treatment of people with complex needs. The trust, as leaders of the learning disability and autism collaborative, had focused on reducing the reliance on inpatient care. This had delivered sustained reductions, which ensured that people were cared for in safe systems and pathways in the community.

The trust worked closely with provider collaborative (colleagues involved in commissioning and coordinating care for people in low and medium secure services),to support discharge planning. This resulted in several patient with the long lengths of stay being discharged to the community. This work, supported by the discharge hub, established a recall bed in the unit for people who were on extended Section 17 leave.

Staff planned for people’s discharge, including good liaison with care managers and care co-ordinators. Staff used a 12-point discharge plan, which was discussed at multidisciplinary review meetings. Staff scored 12 aspects of discharge planning for each person to ensure that all relevant actions had been taken and that discharges were systematically planned. There had been 4 discharges over the past 12 months, 3 to supported living placements and 1 to a rehabilitation unit.

The service held a weekly system discharge planning meeting, attended by the unit’s discharge coordinator. The discharge coordinator also attended learning disability crisis response and intensive support team (CRIST) meetings when a person’s discharge was approaching, to provide updates and support discharge planning. The dynamic support pathway team coordinated post-admission and post-discharge multi-agency meetings, and CRIST contributed to these meetings.

Discharge was never delayed for other than clinical reasons. In the 12-month period from 1 April 2025 to end of March 2026, there had been no delayed discharges or transfers of care from the unit. The average length of stay for the unit was 163 days, with the highest length of stay being 350 days, and the lowest 52 days.

At the time of our inspection, managers were actively exploring further alternatives to hospital admission, by looking at outreaching to people in their own homes. Managers had submitted a proposal to senior leaders, which was in the process of being considered.