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 people were protected from abuse and avoidable harm. During this inspection we considered how people were receiving services in line with Right Support, Right Care, Right Culture.

At our last assessment in 2021, we rated this key question Requires Improvement. At this assessment the rating has changed to good. This meant people were safe and protected. The unit was 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 store medicines. The service managed patient safety incidents well, however there had been an increase in restrictive 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 had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

All staff knew what incidents to report and how to report them. They were able to describe the actions required following an incident and the appropriate escalation routes. The evidence we reviewed demonstrated that staff reported and escalated incidents appropriately.

The trust followed a structured “lessons learned” approach to incidents, which was aligned with NHS national frameworks. The approaches centred on learning, system improvement, and prevention of recurrence rather than blame. The trust had transitioned from the serious incident framework to the patient safety incident response framework (PSIRF) in November 2023. The service followed the national PSIRF model, reviewing incidents for learning in line with the trust’s people safety incident response plan (PSIRP).

All reported incidents were reviewed by ward managers local to the incident and actions were taken as required. Where people came to harm, or where incidents met the trust’s priority criteria, these were escalated for senior review through an initial service manager review (ISMR). ISMRs provided a structured review of incidents, including actions taken, identified good practice and learning.

The trust shared evidence of learning from incidents where the learning from the incident included a change to the multi-agency meeting (MAM) template. This evidenced that learning had reached beyond the service, as the MAM is part of the Dynamic Support Pathway (DSP). The DSP, co-ordinates support for people with a confirmed diagnosis of learning disability, autism, or both who are experiencing a decline in their mental health or wellbeing while living in the community.

The learning from incidents was also evident in the safety huddles which showed that learning from events (which had taken place the previous day), were used to change practice. The use of the virtual noticeboard in the Agnes unit, was a result of staff feedback which ensured that information was accessible to staff to support learning.

Managers reviewed completed ISMRs at directorate review and sign-off meetings to provide oversight of people’s safety issues and identify any further actions required. Learning from ISMRs was shared through the directorate assurance group and disseminated to ward staff via team meetings.

Between 1 April 2025 and 30 April 2026, 3 incidents were categorised as having resulted in moderate harm. All 3 incidents related to assaults on staff, resulting in semi-permanent harm. Managers had completed an ISMR for all 3 incidents. Learning was identified and support was provided to staff via the senior leadership team.

Staff understood and applied the duty of candour. They were open and transparent, providing people and families with a full explanation when things went wrong.

Staff told us the service held quarterly team meetings, with sessions repeated to maximise attendance. Meetings were separated into 2 and scheduled on different dates to ensure maximum attendance. Each meeting included protected time for staff training and development. The purpose of the Agnes unit team meeting was to provide a safe and open forum, with standing agenda items that include staff wellbeing and a check in. The meeting offered a space for open discussions in relation to clinical presentations of people, associated risks and an opportunity for staff to be able to raise any areas of concern and highlight good practice.

Staff received feedback from internal and external incident investigations and discussed the learning in team meetings. The learning disability and autism service used a virtual notice board to share learning, including learning boards developed following investigations. These summarised the incident, findings, learning, recommendations, good practice, actions and next steps. Staff were expected to review the notice board regularly, and managers reinforced learning through team meetings.

The trust produced a quarterly learning report setting out system-wide learning from reviews. Team meeting agendas included recent serious incidents, learning outcomes, actions to be completed and preventative strategies that could be implemented within the unit. Meetings also included trust-wide priorities, so staff understood wider service planning and organisational direction.

The learning disability and autism collaborative quality group reviewed learning from within the service and across the wider system, providing further oversight of themes, actions and improvement work.

There was evidence that learning led to improvements in practice. For example, staff made environmental adaptations, including the provision of a chair in a shower room, to reduce the risk of further injury.

Staff were debriefed following all incidents, including serious incidents, and received appropriate support. The service held post event team reflections and staff support, and safety checks were undertaken at the daily safety huddle. In addition, in line with the post intervention psychological support framework, psychology staff provided structured debrief sessions twice weekly.In addition, in line with the post intervention psychological support framework, psychology staff provided structured debrief sessions twice weekly.

We scored the service as 4. The evidence showed an exceptional standard. The service always worked with people and healthcare partners to design, establish and maintain safe systems of care, in which safety was always well managed and monitored. They made sure there was always continuity of care, including when people moved between different services.

The service’s referral and admission processes ensured that all essential information about people were obtained, to determine whether their needs could be safely met. These assessments included consideration of health conditions such as epilepsy, swallowing difficulties, and behavioural risks.

The service worked closely with the crisis response and intensive support team , who acted as gatekeepers to hospital admission. Staff told us they worked collaboratively with the crisis team in relation to admissions, transfers and discharges.

Staff worked closely with families, healthcare and social care partners to ensure continuity of safe care. The trust was the lead provider for the learning disability and autism collaborative, an example of joined up system working and leadership, which aimed to deliver the best care for the population it serves. The collaborative had developed a provider quality framework for health and social care funded community placements, which focused on putting research into practice.

The trust provided evidence that the ‘Right Care, Right Place and Right Culture’ was delivered at the service. The trust completed comprehensive learning disability and physical health assessments, including annual health checks and ensured person‑centred care through the involvement of patients, carers, families, and advocates.

Staff involved all relevant health and social care services to support continuity of safe care, both within the service and following discharge. Care planning was undertaken in partnership with the person, carers and external professionals, ensuring that information was shared and embedded into support plans. Staff worked alongside a range of professionals, for example speech and language therapy services, community nursing teams and GPs, to ensure continuity of care for people with complex needs such as dysphagia and epilepsy.

Staff ensured effective continuity of care after the person’s discharge from hospital. People were discharged with clearly identified discharge plans, and staff ensured that families were fully involved in handover discussions. Staff described how multidisciplinary working across community and inpatient services, ensured effective discharge.

The provider has worked with the provider collaborative colleagues to support discharge planning for people previously requiring low or medium secure care. This has resulted in several people with long inpatient stays, being discharged from hospital to live in the community. The work (supported by the discharge hub) has established a recall bed in the unit for people who are on extended Section 17 leave.

The dynamic support pathway (DSP) reduced the reliance on inpatient care for people with a learning disability and autistic people. The aim of the pathway was to ensure that any concerns for individuals were identified early, and the support people required was implemented quickly and effectively.

The unit ensured that care was coordinated by the multidisciplinary team to promote independence and successful reintegration into the community. For example, bespoke activity passports, were created for people. These ensured that everyone was aware of how support is tailored in the community.

The Learning Disability Crisis Response Intensive Support Team was well embedded in the service and provided short-term, intensive support for individuals whose behaviours place them and others at risk of placement breakdown or hospital admission. The goal of the team was to understand why someone was needing to use these behaviours. Once understood, the team helped people and their care team find and use strategies, so the patient doesn’t have to rely on these behaviours to get their needs met. Inpatient Consultants worked across both Inpatient and LD CRIST ensuring continuity of care and to support discharge. The trust was in the process of developing a health at home which proposed to build on support already available. This would enable health professionals to provide care at home, in the community and within the Agnes Unit.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Staff were trained in safeguarding, knew how to make a safeguarding alert, and did that when appropriate. Mandatory training compliance was 100% for safeguarding adults’ level 2 and safeguarding children level 2, and 93% for safeguarding adults’ level 3.

Staff were able to tell us when they should make a safeguarding referral and knew the process for making a referral.

The ward completed a monthly learning disability clinical record keeping audit. Between May 2025 and April 2026, the overall compliance was 80%. The audit included a question reviewing whether there was evidence of safeguarding concerns being acted upon, such as a safeguarding checklist, electronic incident report form (EIRF), and contact with social services. The unit had clearly defined governance arrangements for safeguarding through the directorate safeguarding assurance meeting, which reported into the directorate management team meeting and trust-wide safeguarding meeting. In addition, the ward was being included in a trust-wide safeguarding audit, undertaken by an external agency. The objective of the audit was to provide independent assurance on the directorate safeguarding governance arrangements, the process for reporting safeguarding concerns, and to assess staff knowledge and understanding of “think family”. The Think Family approach is a way for care and support services to work together.

There were 2 safeguarding concerns reported during the period from May 2025 to April 2026 that met the threshold for a section 42 enquiry under the Care Act 2014 (a section 42 enquiry is the statutory mechanism for safeguarding adults at risk). The team alerted the local authority regarding both safeguarding concerns. In response, the local authority asked the clinical team to complete the section 42 enquiry templates. The first concern related to a witnessed fall. Learning was disseminated to staff, and the case was discussed at the following oversight meeting and closed. The second case related to the transfer of a person to the extra care suite using non-approved moving and handling techniques. Managers reviewed the incident and actions taken by the service, and at the following trust-wide incident review and learning meeting it was agreed that no further investigation was required.

Staff could give examples of how to protect people from harassment and discrimination, including those with protected characteristics under the Equality Act. The trust has adopted the Patient and Carer Race Equality Framework (PCREF), which outlines how mental health providers embed anti-racism.

Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies. Staff followed safe procedures for children visiting the service. We were told that any visits would take place off the main unit.

There was no evidence of any blanket restrictions being in place on the unit. Any restriction was care planned and individualised. However, the unit had (in line with health and safety requirements) a list of restricted items.

Restrictive interventions had increased significantly over the reporting period, from no restraints in April 2025 to a peak of more than 40 incidents in both November 2025 and February 2026. Between 1 April 2025 and 30 April 2026, there were 230 restrictive incidents. These included 183 episodes of physical restraint: 91 standing, 6 restrictive escort, 5 supine, 11 side, 65 seated, 4 kneeling and 1 not recorded. Of the 193 episodes of physical restraint, 21 (11%) lasted longer than 10 minutes. There were no episodes of prone restraint. Prone restraint is a physical intervention where a person is held face-down, restricting their movement. Staff had reviewed this data and had identified that the needs of one of the people on the ward, would be best placed in an environment of higher security. The provider had taken active steps to address this via referral to commissioners and ongoing multiagency discussions.

Mental Capacity Act

The provider had a policy on the Mental Capacity Act, including deprivation of liberty safeguards. Staff were aware of the policy and had access to it. Staff had received training in the Mental Capacity Act with 99% compliance. Staff had a good understanding of the Mental Capacity Act, in particular the five statutory principles. Staff knew where to get advice from within the provider regarding the Mental Capacity Act, including deprivation of liberty safeguards.

Staff took all practical steps to enable people to make their own decisions. For people who might have impaired mental capacity, staff assessed and recorded capacity to consent appropriately. They did this on a decision-specific basis regarding significant decisions. However, we found that capacity and best interests assessments had not always fully met best practice. For example, one person’s records showed that, while the person had a capacity assessment and a best interest assessment in place, these had last been completed in December 2025 and August 2025 respectively. This did not provide assurance that the provider was consistently acting in accordance with the Mental Capacity Act 2005 and Regulation 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Assessments were not always decision-specific or reflective of the person’s current circumstances.

When people lacked capacity, staff made decisions in their best interests, recognising the importance of the person’s wishes, feelings, culture and history. We reviewed the records of one person where a best interest assessment had been undertaken in relation to the person’s need for physical healthcare. The best interest assessment included the lead consultant from the local acute hospital.

Staff made deprivation of liberty safeguards applications when required and monitored the progress of applications to supervisory bodies. For example, staff had completed deprivation of liberty safeguards (DoLS) assessments in relation to restrictions associated with locked doors requiring door codes.

The service had arrangements to monitor adherence to the Mental Capacity Act. Staff audited the application of the Mental Capacity Act and took action on any learning that resulted from it.

We scored the service as 3. The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. Staff assessed and managed risks to people and themselves well and followed best practice in anticipating, de-escalating and managing challenging behaviour. Staff used restraint and seclusion only after attempts at de-escalation had failed. The ward staff participated in the provider’s restrictive interventions reduction programme. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The Agnes unit utilises Positive Behaviour Support (PBS) plans for people. The plans equipped staff with strategies to recognise when a person was becoming distressed and to know how they best support people in these situations. The PBS is a person centred, proactive strategy to understand and manage distressed behaviours The PBS plans focused on improving quality of life for individuals with learning disabilities or autism.. At the time of our inspection, 66 staff had received training on PBS. A quality improvement initiative was also underway to identify how the trust could improve the PBS to make it more accessible for peoples.

The Trust had invested in additional training for staff to increase sensory awareness and undertake communication and functional assessments. People also received access to individual psychology which provided a wide range of bespoke support for people of the unit.

Staff took a positive risk-taking approach to encourage people to participate in activities on and off the unit. This included this includes visits to a local farm, shopping and accessing parks and recreation spaces. Staff also listened to peoples’ needs and arranged trips to the seaside, local singing groups and attendance at special Olympic events].

The service has developed several guidelines to inform decision making, including for trauma and epilepsy. The service had also worked to improve the uptake of cervical screening for people with a learning disability, which included access to an educational video.

During our inspection, we reviewed the risk assessments and risk management plans for all 3 people on the unit. These were up to date and had been reviewed by the clinical team at the weekly multidisciplinary meeting and after any risk incident.

Between 1 April 2025 and 30 April 2026, there were 37 episodes of rapid tranquillisation. This included 32 episodes of intramuscular rapid tranquillisation and 5 episodes involving oral medication. Staff completed post-rapid tranquillisation observations in line with trust policy.

The provider shared data in relation to long-term segregation over the 12-month period 1 April 2025 to 30 April 2026. The data showed that there was 1 person in long term segregation for the 5-month period April to August 2025 and March 2026. In addition, 2 people were in long-term segregation during the 6-month period from September 2025 to February 2026. All episodes of long-term segregation were implemented in line with trust policy and were the least restrictive option for the people involved.

There had been 9 episodes of seclusion between June 2025 and January 2026. The 9 episodes of seclusion related to 2 people on the unit. The restrictive incident data was reviewed through the inpatient assurance meeting within both the directorate and trust-wide least restrictive practice group. The meetings reviewed the seclusion data to ensure that staff had followed trust policy, that the episode of seclusion was appropriate and that the duration of seclusion was appropriate to the person’s presenting needs.

Staff had enabled people to give feedback on the service they received (for example, via surveys or community meetings). Staff told us that they spoke with people weekly using the “My Voice questionnaire”. People were given the opportunity to describe “what's been good this week, what's made me sad, how was leave”, and anything they would want to discuss at their multidisciplinary meeting. The outcome of the questionnaire was then discussed with members of the MDT, and a member of the team then met with the people to discuss their responses. Responses from people included compliment on the care and treatment provided. For example, staff “provided strategies on how to manage behaviour and supported us and shared how to communicate”.

Staff ensured that people could access advocacy. Staff told us that people had access to independent (non-statutory) care advocacy and independent mental health advocates (IMHAs), a legal advocacy role created by the Mental Health Act 1983. People had access to Independent Mental Capacity Advocates (IMCAs) for key decisions in relation to the Mental Capacity Act.

We scored the service as 2. The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

The unit complied with guidance on eliminating mixed-sex accommodation. At the time of our inspection each of the 3 people were being nursed in a separate pod. The pods were separate ward areas which had 4 bedrooms with ensuite facilities, kitchen dining and sitting areas. Staff informed us that in the event of a new admission, that the pods would become single sex.

Staff completed regular risk assessments of the environment. On a weekly basis, the deputy ward sister or charge nurse reviewed the environmental checks, to ensure that all areas were completed and appropriate action taken.

The trust had carried out an annual ligature risk assessment of the unit and had developed a mitigation plan for identified risks in communal areas. The plan set out the actions staff should take to reduce and manage these risks.

However, staff, carers and families raised concerns about the environment, describing it as institutional, clinical and at times claustrophobic, with narrow corridors and multiple doors. Concerns were also raised regarding accessibility and the availability of appropriate equipment, including ceiling hoists. While risks were mitigated, this did not always support a therapeutic environment for people who had mobility needs. The trust had improvement plans agreed to address these concerns and were in the process of getting these approved.

Staff had easy access to alarms and people had easy access to nurse call systems. All staff were given an alarm on commencement of their shift.

The seclusion room allowed clear observation but did not include toilet facilities, which did not meet best practice standards. This had been identified previously and remained on the risk register, with mitigation through staff observation and escort arrangements. Whenever possible staff escorted patient to the toilet (which was near the seclusion room). When this was not possible staff would provide patients with bed pans, which staff would remove from the room immediately after use.

There was one main clinic room on the unit, which was equipped with the necessary equipment and emergency medicines for staff to access when required.

We scored the service as 3. The evidence showed a good standard. The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Managers had calculated the number and grade of nurses and healthcare assistants required. The trust told us staffing levels were based on the number of people admitted to the unit and acuity. Planned staffing levels for nurses and healthcare assistants were met on all shifts.

As of March 2026, there were no vacancies for registered or unregistered nurses. There had been highest registered nurse vacancies in May, November and December 2025, and January 2026, with the highest vacancy rate of 2.5%. There were no unregistered nurse vacancies between April 2025 and March 2026. There were also no medical vacancies. The vacancy rate for allied health professionals was 6% throughout this period, although managers told us that these posts had not been filled because of the reduced number of people.

The average turnover rate from April 2025 to March 2026 was 5%. The highest turnover rate was 7.4% in March 2025, and the lowest turnover rate was 1.5% in June 2026.

The service’s average staff sickness from April 2025 to March 2026 was 7.99%. The highest sickness levels were 11.6% in December 2025.

The ward manager could adjust staffing levels daily to reflect case mix. Managers used bank and agency staff when required to maintain safe staffing levels. Temporary staff (who were regularly deployed on the ward), were familiar with the people, staff and environment, and received an appropriate induction when used. Most temporary staff were healthcare support workers who knew the service.

A high proportion of temporary staff were regular workers, which supported continuity of care. This included 70% of bank staff and 87% of agency staff, who were familiar with the people, staff and systems at the unit. In addition, 93% of non-registered nursing shifts requiring temporary cover were filled by trust bank staff. All shifts requiring temporary staffing were filled, with no unfilled shifts reported.

A qualified nurse was present in each of the 3 pods during the day. Overnight, there was no qualified nurse based in pod 3 because there was no identified clinical need. Qualified nurses remained present in the other 2 pods, which were close to pod 3 and to each other.

Staffing levels allowed people to have regular one-to-one time with their named nurse. At the time of our visit, people had specific staff allocated to their pod. This meant that staff were always available for 1:1 input.

Staff shortages had not resulted in escorted leave or ward activities being cancelled. People and staff told us that people had access to a wide range of activities both on and off the ward. People had a 7-day timetable of meaningful activities, therapeutic interventions and daily routines, including support with sleep hygiene. Staff provided 35 hours of activity each week, both on the unit and in the community.

There were enough staff to undertake physical interventions safely, including observations, restraint and seclusion. Staff had received appropriate training to do so. Staffing levels ensured that staff were always available to carry out physical health observations.

There was adequate medical cover day and night and a doctor could attend the ward quickly in an emergency. The ward always had access to a consultant and medical staff. The trust had also employed a general practitioner (GP) who worked on the unit on a sessional basis, focusing on the physical healthcare of people.

Staff had received and had completed mandatory training. The trust classified mandatory training as core mandatory, clinical mandatory and role essential. The overall mandatory training rate was 98.19%. All training compliance levels were above 93%. The training was appropriate for the people group using the service.

Staff were required to complete tier 1 and tier 2 of the Oliver McGowan mandatory training on learning disability and autism, which was provided by the integrated care board (ICB). Over the previous 2 years, the ICB had introduced phased compliance requirements for each tier. From 2026, the trust was expected to meet the standard course compliance target of 85%. The trust’s completion rate for tier 2 Oliver McGowan training at the time of inspection, was 95.7%.

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Staff maintained equipment well and kept it clean. “Clean” stickers were visible and in date. Ward areas were clean, well-furnished and well maintained. The ward had recently had new doors installed that required staff to use a key fob for access. This had resulted in some minor repair work, which was in progress at the time of our inspection.

Cleaning records were up to date and showed that ward areas were cleaned regularly. The trust had detailed cleaning schedules for all clinical areas. The trust conductedcleaning audits of the 3 ward areas in use. In April 2026, audit results were 100% in all areas (with the exception of 1 corridor, which scored 88%). Mattress audit results were 100% in each month from April 2025 to March 2026.

Staff followed infection prevention and control principles, including hand hygiene. Staff were bare below the elbows and understood the importance of following infection prevention and control measures. Monthly hand hygiene audit results were 100% for each month between 1 May 2025 and 30 April 2026.

The cleaning audit results for each of the 3 pods in use at the time of inspection showed that pod 1 and pod 3 scored 99%, and pod 2 scored 100%. The average ward laundry audit result from April 2025 to the end of March 2026 was 95.36%.

We scored the service as 3. The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

Staff followed good practice in medicines management (that is, transport, storage, dispensing, administration, medicines reconciliation, recording, and disposal of covert medication) and did it in line with national guidance. The trust used electronic prescribing, and medication management was closely monitored by pharmacy.

The average medication management audit result (conducted between April 2025 and end of March 2026) was 96%. The highest result of 100% was in October 2025 and the lowest, 91% was in January 2026. In addition, the trust undertook a monthly audit of documentation in relation to rapid tranquillisation. The results for the 9 months when rapid tranquillisation was used (May 2025 to May 2026), was 99%.

Staff reviewed the effects of medication on people’s physical health regularly and in line with National Institute for Health and Care Excellence (NICE) guidance, especially when the person was prescribed a high dose of antipsychotic medication. The trust participated in a national programme to improve the quality of life of autistic people and people with a learning disability by promoting the right medication, at the right time, for the right reason. STOMP (Stopping over-medication of people with a learning disability, autism or both) is a national project involving many different organisations, which are helping to stop the overuse of psychotropic medications to manage behaviour. The programme (embedded across inpatient and community pathways) included care and treatment reviews, multidisciplinary team reviews, discharge summaries and annual health checks.

Staff reviewed the effects of medicines at the weekly multidisciplinary meetings or when required. Medication care plans were in place focusing on using the right medicine, at the right time, for the right reason.

People received monthly structured psychotropic medication reviews, with clear documentation of indication, benefit, side effects and opportunities for deprescribing. The trust had a dedicated learning disability STOMP email route, which supported communication between consultants and GPs.

The trust had maintained antipsychotic, PRN (pro re nata – as required) and polypharmacy rates below national averages through audit, quality improvement and liaison with primary care. Dashboards supported benchmarking, and annual STOMP audits with action plans were used to monitor and drive improvement.