Leicestershire Partnership NHS Trust

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• 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.

Leaders had the skills, knowledge and experience to oversee the service and promote a positive, open and person-centred culture. Staff described leaders as visible, approachable and supportive, and said they felt able to raise concerns. The trust had clear governance systems from ward to board, with risks, incidents, audits and quality improvement work reviewed through established governance meetings. Leaders understood the main risks to the service, including the environment, restrictive practice and staff wellbeing, and had taken action to monitor and respond to these. The trust worked effectively with system partners and chaired the learning disability and autism (LDA) collaborative, which brought local partners together to improve pathways, share learning and support delivery of the Right support, right care, right culture statutory guidance. The service also showed evidence of learning, improvement and innovation, including work to reduce unnecessary admissions, support discharge, improve accessible information and address health inequalities for people with a learning disability and autistic people.

This service scored 79 (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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The trust had a shared vision, strategy and culture that was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding and meeting the needs of people and the communities served. The trust (together with a partner NHS foundation trust) had a new strategy (THRIVE) developed through consultation with people and their carers, partner agencies and staff consultation. The strategies aim is to achieve the trust’s vision of: ‘together we thrive; building compassionate care and wellbeing for all’, by 2030. The THRIVE strategic priorities underpin the strategy. They stand for technology; healthy communities; responsive; including everyone; valuing our people ​and efficient and effective. ​

The trust also chaired the learning disability and autism (LDA) collaborative, which brought local system partners together to support delivery of the right support, right care, right culture statutory guidance.

Staff knew and understood the provider’s vision and values and behaviours, and how they were applied in the work of their team. The provider’s senior leadership team had successfully communicated the provider’s vision and values to the frontline staff in this service.

Staff had the opportunity to contribute to discussions about the strategy for their service, especially where the service was changing. Staff told us that they felt listened to and that their contributions were valued. Staff could explain how they were working to deliver high quality care within the budgets available.

The trust had a staff strategy in place, which included a range of support mechanisms for staff. Examples included a focus on staff safety and security, zero tolerance (to any threatening, discriminatory, or harassing behaviour), support following an incident, including post-event team reflection, and a range of health and wellbeing support and resources.

In line with national initiatives to reduce unnecessary hospital admissions, leaders had submitted a proposal for service change, which was supported in principle by the executive management board on the 5 May 2026. The proposal was for the Agnes Unit to move to a hybrid inpatient and community-based model. The capacity would reduce from 3 pods to 2, providing 8 beds. The third pod would operate as virtual capacity, delivering intensive step-up and step-down support to people in their own homes through a structured 12-week pathway, including short-term 24-hour support where required. The proposed change aims to reduce unnecessary admissions, shorten lengths of stay and support people to remain safely in the community. The proposed clinical model was developed through a project group involving clinicians, which had clear communication and engagement plans and robust governance arrangements in place.

We scored the service as 3. The evidence showed a good standard. The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

The trust had inclusive leaders at all levels who understood the context in which care, treatment and support was delivered, and who embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively and do so with integrity, openness and honesty.

All staff described leaders as being supportive. Leaders had a good understanding of the services they managed. They could explain clearly how the teams were working to provide high quality care. Leaders had the skills, knowledge, and experience to lead and manage the hospital and ensure the delivery of safe, high-quality care for people.

Staff felt all leaders were visible, approachable for people and staff, and supportive. This included members of the trust board, who undertook visits to the service. Outputs and actions from these visits were discussed in the executive management board and within directorate meetings via feedback shared with the teams. Staff said they were clear about the standards expected of them. Leaders had empowered staff to make decisions and act as needed. Staff told us that leaders made them feel valued and respected. Leaders were viewed by staff and people as hard working and committed.

Leaders stressed the importance of the leadership behaviour framework. The "it starts with me" framework defines expected leadership and staff behaviours. It is built on 5 core pillars: valuing one another, embracing differences, working together, taking personal responsibility, and continually learning and improving. The chair of the LDA group meeting (reflected in the minutes of the meeting for July 2025) reminded everyone of the leadership behaviours and the responsibility of leaders to adhere to them and lead by example.

Leadership development opportunities were available, including leadership training opportunities for staff.

We scored the service as 3. The evidence showed a good standard. The service fostered a positive culture where people felt they could speak up and their voice would be heard.

People and carers had opportunities to give feedback on the service they received in a manner that reflected their individual needs. People also provided feedback on the Agnes unit via the friends and family test. The result for quarter 4, from January to March 2026, showed a 100% result rating of ‘very good’.

People were able to provide feedback through community meetings. Staff responded to each issue raised with an easy-to-read response. Managers and staff had access to the feedback from people, carers and staff and used it to make improvements. People and carers were involved in decision-making about changes to the service. The trust strategy and service development plans had been coproduced with people being actively involved throughout the process.

People and staff could meet with members of the provider’s senior leadership team and governors to give feedback. The senior leadership had a programme of service visits. All staff told us that they knew who their leaders were and that they were approachable.

Staff had access to the trust’s freedom to speak up’ (FTSU) process. Also in April 2026 the trust launched an FTSU reporting tool in response to feedback from staff to maximise the methods available to speak up.The trust had developed an easy to-use checklist for staff, along with a poster which outlined ways in which staff could raise any concern. Leaders encouraged speaking up and raising concerns, which was supported by 2 FTSU guardians and 24 FTSU champions across the trust.

Staff had raised one FTSU concern in March 2026, relating to the levels of violence and aggression, and the impact this was having on staff wellbeing. Concerns relating to this person were already known and actions were being taken to support staff on the unit and progress the person’s discharge to a more appropriate placement.

The FTSU guardians held a listening event after staff raised the concern to ensure staff voices were heard. During the event, 3 additional staff members raised the same concern. The guardians escalated the concerns, and senior staff, including the chief medical officer, deputy director of nursing and quality, and restrictive practice lead, undertook support visits. The senior directorate team also provided support. The chief medical officer held weekly meetings to monitor the situation and support the person’s transition to a more appropriate setting via the regional commissioning team.

Staff participated in the NHS staff survey. Five priority areas were identified from the last staff survey. These included staff motivation and engagement; career development and meaningful appraisals; workload pressure, unpaid hours and burnout; recognition, feeling values and retention risk; staff involvement in decisions and change. Actions had been identified in response to each of the 5 priority areas to address the areas identified for improvement.

The trust participated in the Leicestershire, Leicester and Rutland freedom to speak up meeting, where themes and learning was shared. Joint actions were also agreed to enable collective working to introduce improvement to benefit staff.

We scored the service as 3. The evidence showed a good standard. The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

The trust’s equality, diversity, and inclusion strategy set out how the trust aimed to create a highly inclusive culture that meets the needs of all staff, people and communities. Leaders identified equality and culture change as one of the key priorities in the trust’s THRIVE strategy and culture change programme ‘our future, our way’ programme.

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. Priorities agreed for this year in the trust, included focus on workforce and cultural awareness, coproduction and lived experience and partnership working.

The trust undertakes equality monitoring of staff within the service to ensure it is diverse in its make-up and representative of the patient group. In the April 2026 meeting of the equality, diversity and inclusion workforce group meeting, it was reported that 70% of interview panels were diverse in relation to gender, and Black, Asian, and minority ethnic backgrounds.

The trust reported strong progress in relation to the workforce race inequalities and inclusion programme (WRES) and workforce disability equality standard (WDES), with several positive recorded (inclusive recruitment training, reasonable adjustment clinics, reverse mentoring and a narrowing of the gender and ethnicity pay gaps). Staff (100%) were trained in equality, diversity, inclusion, and human rights.

The trust had ensured that staff are able to apply to work flexibly. For example, flexible working agreements were available to account for personal circumstances such as caring responsibilities and health issues. Managers put reasonable adjustments in place for staff members to help them carry out their role.

We scored the service as 3. Theprovider had clear responsibilities, roles, systems of accountability and goodgovernance. They used these to manage and deliver good quality, sustainable care,treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

There was a clear framework of what must be discussed at ward, team or directorate level in team meetings, to ensure that essential information, such as learning from incidents and complaints, was shared and discussed.

The trust had a clear governance structure from ward to board, including clearly identified delivery and assurance groups. Leaders attended the LDA governance meeting, which had a set agenda, including a specific section of the meeting for the Agnes unit.

The trust together with a partner NHS foundation trust, had reviewed their board assurance frameworks, corporate risk registers and accountability framework. The trust had a list of accountabilities for each executive director, which is regularly reviewed and updated. An Accountability Framework Meeting is in place which uses data to hold staff from the wider directorate leadership and enabling teams to account on performance.

The Trust had a framework for managing risk. This ensured that risks in relation to the delivery of services and care to people are minimised, that the wellbeing of people, staff and visitors was optimised and that the assets, business systems and income of the Trust were protected, and where possible opportunities were maximised. Staff had implemented recommendations from reviews of deaths, incidents, complaints and safeguarding alerts at the service level.

Staff undertook or participated in local clinical audits. The audits were sufficient to provide assurance and staff acted on the results when needed. For example, the service undertook a clinical record keeping audit monthly for all people. The audit consisted of an assessment of need and risk including initial and ongoing care planning and evaluation, people involvement and information and miscellaneous Between the period of May 2025 to April 2026, the overall compliance was 80%.

Staff understood the arrangements for working with other teams, both within the provider and external, to meet the needs of the people.

The trust collected performance and risk data in a way that was not burdensome for frontline staff. Team managers had access to timely and accurate data about performance, staffing and patient care, which they used to monitor quality and identify areas for improvement. Staff also had access to the equipment and IT systems they needed, including effective record-keeping systems that supported confidentiality and good information governance.

Staff maintained and had access to the risk register at ward or directorate level. The ward had an identified risk in relation to the seclusion room, which did not meet best practice. Leaders were taking a range of actions to address the issue, including proposed estate works and costings. Staff at ward level could escalate concerns when required. Staff concerns matched those on the risk register.

Staff had access to the equipment and information technology needed to do their work. This included visualisation screens, which support real-time monitoring of people’s’ observations. The visualisation screens provide a clear overview of the person’s current status, highlighting any overdue observations and help inform interventions. The information technology infrastructure, including the telephone system, worked well and helped to improve the quality of care.

Information governance systems included confidentiality of people’s records. The reporting and management of data, information, cyber and wider security risks were supported by the trust’s risk system. The trust monitored any breaches, ensured staff received training and undertook phishing exercises to promote IT security. The trust ensured that all staff were reminded of their data security responsibilities through education and awareness. The data privacy team regularly shared key messages as reminders or as part of learning from incidents and ran awareness campaigns on specific topics. Data security training formed part of mandatory training requirements.

Team managers had access to information to support them with their management role. This included information on the performance of the service, staffing and people’s care. Information was in an accessible format, and was timely, accurate and identified areas for improvement.

We scored the service as 3. The evidence showed a good standard. The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

The trust fully understood it’s duty to collaborate and work in partnership with a wide range of statutory and non-statutory agencies, so services worked seamlessly for people. Staff shared information and learning with partners and collaborated with a wide range of partners to promote service improvement. Leaders worked with people and external stakeholders to ensure that people’s engagement and co-production was well embedded across the service. This included the work of the learning disability and autism (LDA) collaborative, which was chaired by the trust and brought together system partners to improve pathways, share learning and support delivery of person-centred care.

The trust actively engaged with system and national partners and agencies to ascertain the needs of the local population. System working had assisted the trust to determine how the services currently being provided by the trust needed to adapt.

The trust strategy outlined the importance of open and transparent leadership. Leaders collaborated with all relevant external stakeholders and agencies in the design and mobilisation of the trust’s strategic objectives. This included promotion of freedom to speak up, and valuing the voice of people, those the trust cared for and their families.

Leaders used health inequality data, in partnership with another NHS foundation trust, to inform transformation plans across the trust. Staff were committed to continuous improvement and worked with communities to co-design solutions. This collaboration helped the service understand local health inequalities and develop local plans to address them. Improvements focused on strengthening pathways for people, including access, experience and outcomes.

We scored the service as 4. The evidence showed an exceptional standard. The service had a strong focus on continuous learning, innovation and improvement across the organisation and local system. They always encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contribute to safe, effective practice and research.

Staff were given the time and support to participate in quality improvement initiatives. Staff used quality improvement methods and understood how to apply them, and several innovations were taking place in the service. Quality Improvement (QI) methodology was fully embedded at Trust, directorate and ward level. All staff were encouraged to suggest ideas for QI, these were tracked and supported with expertise being provided as needed.

Quality improvement plans (QIP) were governed via the QIP subgroup meeting. An annual QIP workplan had been developed and quarterly highlight reports had been provided to both the Directorate Management Team Meeting and to the LDA Collaborative Delivery Group. The QIP priorities are driven by the Trust THRIVE strategy and the LDA service goals.

The overall impact of the work completed in 2025 to 2026 had delivered significant progress in service modernisation, pathway clarity, and digital transformation, improved clinical efficiency, reduced duplication, and safer waiting list management. QI projects had also strengthened people, carer, and system collaboration, supporting more equitable access to services.

An overview of all QI projects were received by the directorate management team monthly, as part of the divisional management team (DMT) transformation agenda. At the time of our inspection, staff were undertaking several quality improvement projects. For example, one project aimed to assess, review and improve the quality of annual health checks offered to people with a learning disability. Staff also participated in national audits relevant to the service and learned from them.

Staff had opportunities to participate in research. At the time of inspection staff were undertaking several research projects and contributing to national publications. Two examples of research projects included a quality improvement research project into engagement of adults with learning disability from ethnic minority backgrounds within the East Midlands. The aim of the project was to increase understanding of barriers and facilitators to clinical engagement and research involvement for adults with a learning disability from minority ethnic backgrounds, residing in the East Midlands. A further study was exploring epilepsy-related premature mortality in adults with a learning disability.

The unit participated in relevant accreditation schemes and learned from them. It held accreditation with the Quality Network for Learning Disability Services (QNLD) from 11 December 2023 to 20 February 2026. At the time of our inspection, the unit was preparing for the next accreditation cycle, with the self-assessment due in July 2026 and the peer review visit scheduled for September 2026.