Leeds and York Partnership NHS Foundation Trust

Updated 20 December 2019

Not used

Updated 20 December 2019

Updated 18 December 2025

Leeds and York Partnership Foundation Trust provide acute inpatient services for adults of working age with mental health problems. These services are for both patients admitted informally and those detained under the Mental Health Act 1983.

The purpose of the wards is to provide assessment and treatment to people aged 18-65 who require hospital admission in an acute phase of their mental health illness.

The service consists of one psychiatric intensive care unit and five acute wards, located at two main sites: The Newsam Centre and the Becklin Centre.

The wards located at the Newsam Centre are:

• Ward 1, a 12-bed mixed gender psychiatric intensive care unit, and
• Ward 4, a 21-bed male acute ward.

The wards located at the Becklin Centre are:

• Ward 1, a 22-bed female acute ward
• Ward 3, a 22-bed male acute ward
• Ward 4, a 22-bed male acute ward, and
• Ward 5, a 22-bed female acute ward.

We last inspected the acute wards for adults of working age and psychiatric intensive care units in October 2019. At that inspection, we rated the service as good across all domains, and good overall.

Our inspection took place on 3, 4 and 5 February 2025. We inspected all wards and all five key questions: safe, effective, caring, responsive, and well-led. The inspection was unannounced (staff did not know we were coming) to enable us to observe routine activity. We gathered information from people using the service, their loved ones, staff and other external stakeholders. We observed the care being provided and reviewed a range of documents relating to the running of the hospital.

Our rating of this service went down. We rated it as requires improvement because the service did not always ensure that care and treatment is provided in a safe way to patients. This meant that the service was in breach of Regulation 12 Safe care and treatment because:

• There were blind spots on wards at the Becklin Centre which staff had not identified or recorded on the suicide prevention environmental audits.
• There was a door within the quiet room on Ward 4 at the Newsam Centre which had ligature points that had not been identified or recorded on the suicide prevention environmental audits.
• Staff did not always follow good infection prevention and control procedures in line with organisational policy. We saw that staff across the wards were not always bare below the elbows.
• Staff did not always assess patients’ physical health in a timely manner on admission. Data provided by the trust provided showed that some patients did not receive a physical health assessment until over a month after admission.

We also found that the service did not always ensure sufficient numbers of suitably qualified, competent, skilled and experienced persons are deployed to meet the fundamental standards of care and treatment. This meant the service were in breach of Regulation 18 because:

• There were areas of non-compliance for mandatory training including fire safety.

We also found that the service did not always ensure the care and treatment of patients is appropriate, meets their needs and reflects their preferences. This mean the service was in breach of regulation 9 because:

• Care plans were generic and lack evidence of patient involvement.

We also found that the service did not always establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care. This meant the service were in breach of Regulation 17 because:

• Managers and leaders had not taken appropriate steps to address issues with mandatory training.
• Managers and leaders did not have sufficient oversight of care records and had not taken appropriate action to ensure staff completed physical health assessments in a timely manner on admission.

However:

• Staff received lessons learned from the investigation of incidents, complaints and safeguarding concerns, both internal and external to the service. Staff met to discuss lessons learned and were debriefed and received support after incidents.
• Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.
• Staff we spoke with understood the patient group including individual risks, and how they needed to engage with them.
• There was evidence of effective joint working with a range of internal and external teams. Managers had regular engagement with stakeholders and external services, inviting them to regular meetings and care programme approach meetings.
• There were robust processes in place for the investigation and management of complaints.
• Staff encouraged patients to live healthy lives, and there were a range of activities available to them.
• There were quality improvement projects in place which aimed to improve the quality-of-care patients received.

We have asked the trust for an action plan in response to the concerns found at this assessment.

Updated 18 December 2025

Leeds and York Partnership NHS Foundation Trust is registered with the Care Quality Commission to deliver the following regulated activities:

• Personal Care
• Nursing care
• Treatment of Disease, Disorder or Injury
• Assessment or medical treatment for persons detained under the Mental Health Act 1983
• Diagnostic and Screening procedures.

We carried out an unannounced on-site inspection visiting all 3 long stay or rehabilitation mental health wards for working age adults at Leeds and York Partnership NHS Foundation Trust on the 10 and 11 March 2026.

We gathered information from patients and their family/carers, staff and managers, other stakeholders and our own observations of care. We reviewed a range of documents including care records, policies and procedures. We looked at all quality statements.

We visited the following sites:

• Asket Croft - a 20-bedded mixed-gender community inpatient unit that provides a supportive setting for service users in the early stages of their recovery who have a higher level of need.
• Asket House - a 16-bedded mixed community inpatient unit that provides a more independent setting for service users with a lower level of need and who are further on in their recovery but still require 24-hour support provided by the multidisciplinary team.
• Newsam Centre Ward 5 – a 17-bedded male locked ward that offers complex rehabilitation to men aged 18-65.

The inspection was planned due to the length of time since our previous inspection.

The long stay or rehabilitation mental health wards for working age adults were last inspected in 2019 and were rated requires improvement with breaches of Regulation in the following areas:

• Regulation 12 – Safe Care and Treatment
• Regulation 18 – Staffing
• Regulation 17 – Good Governance

At this assessment we found 4 breaches of regulation. These were Regulation 12 safe care and treatment, Regulation 15 Premises and equipment, Regulation 17 Good governance and Regulation 18 Staffing.

Mental Health Act and Mental Capacity Act Compliance Summary

The provider had relevant up to date policies relating to the Mental Capacity Act and the Mental Health Act and staff could access advice on the implementation of the Mental Health Act.Staff received training in the Mental Capacity Act and the Mental Health Act and training compliance levels were as follows. For the Mental Health Act Asket Croft was at 87%, Asket House was at 82% and Newsam Ward 5 was at 86%. For Mental Capacity Act Asket Croft was at 86%, Asket House 91% and Newsam Ward 5 was at 83%.

Staff assessed patients capacity on a decision specific basis with regard to significant decisions and recorded best interests’ decisions where this was required. However, there was one occasion on Newsam Ward 5 where a best interest meeting had not been documented as taking place in relation to a safeguarding concern. We were however, assured that action had been taken to safeguard the patient in relation to the concern and ongoing discussion were documented regarding the patients care.

Staff ensured patients could take Section 17 leave (permission to leave hospital) and explained their rights in a way they could understand and repeated this where necessary. Patients had access to advocacy.

Updated 18 December 2025

The Mount is the only inpatient site at Leeds and Yorkshire Partnership NHS Foundation Trust for older people who require hospital admission. There are four wards that provide assessment, treatment and rehabilitation for older people with acute mental health needs including dementia. The service provides care for patients who require admission under the provisions of the Mental Health Act 1983. It also provides care for patients who may require a deprivation of liberty safeguards authorisation and informal patients who have agreed to receive care and treatment there. The wards are:

• Ward 1, a male ward specialising in dementia care
• Ward 2, a female ward specialising in dementia care
• Ward 3, a male mental health ward
• Ward 4, a female mental health ward

We previously inspected wards for older people with mental health problems in October 2019. At this inspection we rated the services as good overall, safe as requires improvement and effective, caring responsive and well-led as good.

Our inspection took place between 3 and 5 February 2026. We inspected all wards and all five key questions: safe, effective, caring, responsive, and well-led. The inspection was unannounced (staff did not know we were coming) to enable us to observe routine activity. We gathered information from people using the service, their loved ones, staff and other external stakeholders. We observed the care being provided and reviewed a range of documents relating to the running of the services.

Our rating of this service went down. We rated it as requires improvement in safe and well-led and requires improvement overall because the service did not always ensure that care and treatment was provided in a safe way to patients.

The service was in breach of Regulation 12 Safe care and treatment because:

• Staff were not consistently recording physical observations of patients that required them, this meant the service could not be assured they had taken place.
• Staff had not recorded physical health observations for the duration described in trust policy following administration of an injection prescribed for one patient. This was an issue that had been identified at our previous inspection of the service
• There was no process in place to ensure staff were routinely cleaning medical equipment.
• Staff were not clear where the wards ligature cutters were located or what process they needed to follow if they had to be used.

The service was in breach of Regulation 17 Good governance because:

• Evidence from other key questions indicated that systems and process to assess and monitor the provision of safe care were not always established or effectively operating.
• The trust had failed to take the necessary action to improve practice in relation to the recording physical health observations following administration of injections. This was an issue that had been identified at our previous inspection of the service.

The service was in breach of Regulation 18 Staffing because:

• Staff were not compliant with their mandatory training. Fire level 3 training, smoking cessation training, therapeutic engagement and observation level 2 training and Mental Health Act training were all below 75%.

However:

• Staff received lessons learned from the investigation of incidents, complaints and safeguarding concerns, both internal and external to the service. Staff met to discuss lessons learned and were debriefed and received support after incidents.
• Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.
• Staff we spoke with understood the patient group including individual risks, and how they needed to engage with them.
• Staff encouraged patients to live healthy lives, and there were a range of activities available to them.
• There were quality improvement projects in place which aimed to improve the quality-of-care patients received.

• Feedback from patients and carers was very positive, they said that staff were caring, kind and considerate and they worked hard to deliver safe and effective care.

We have asked the trust for an action plan in response to the concerns found at this assessment.

Updated 23 September 2025

We assessed Leeds and York Partnership NHS Foundation Trusts, Child and Adolescent Mental Health wards on the 28 and 29 October 2026.

We visited all the Trusts child and adolescent mental health wards, which were located over two sites:

• Mill Lodge which was a 10-bed general adolescent ward
• Red Kite View which contained two wards, a 16-bed general adolescent unit and a separate 6 bed Psychiatric Intensive Care Unit (PICU). However, the day before we visited Red Kite View, patients from the PICU were relocated to another ward within Red Kite View due to an environmental issue. Therefore, the general adolescent ward had been split in two to accommodate the PICU patients.

We rated the service as good. We found a breach of regulation 12, safe care and treatment, in relation to medicine management and mandatory training.

We assessed the service against ‘Right support, right care, right culture’ guidance to make judgements about whether the provider guaranteed people with a learning disability and autistic people respect, equality, dignity, choices, independence and good access to local communities that most people take for granted.

We carried out 3 short observational framework for inspections (SOFIs) which is an observational tool used to capture the experiences of service users who may not be able to express this for themselves.

We gathered information from young people using the service and their families and/or carers, staff and managers, stakeholders and we also carried out our own observations. We reviewed a range of documents including care records, policies and procedures. We looked at all 33 quality statements.

We have asked the provider for an action plan in response to the concerns found at this assessment.

Updated 16 August 2024

The Yorkshire and Humber Mother and Baby Unit in Leeds is a specialist service consisting of one 8-bed ward for women in the late stages of pregnancy or who have a baby under the age of 1 year old, who require an in-patient stay with their baby due to a mental disorder arising in the perinatal period. The ward provides a regional service to people living in Yorkshire and Humber. The ward has never been inspected since it opened. This assessment has been completed following Care Quality Commission (CQC) new approach to assessment; Single Assessment Framework (SAF). We carried out our assessment on 10 and 11 September 2024. This was an unannounced assessment, which meant the provider did not know we were coming. During this assessment we looked at all quality statements across all 5 key questions. As we assessed all quality statements at this visit, it means the current rating reflects the findings from this assessment. Overall, the service was rated as good, but, we found a breach of the legal regulation in relation to good governance. We have asked the provider for an action plan in response to the concerns found in relation to monitoring of mandatory training.

Updated 18 November 2016

We rated community mental health services for adults with learning disabilities or autism as good because:

• Staff included patients and carers in their care and treatment. Patients and carers felt involved in their care. Leeds autism diagnostic service involved a patient in training videos which were used in staff training to show living with autism from an individual’s perspective.

• Care and treatment was delivered in line with best practice evidence and guidance. Staff followed guidance and recommendations when prescribing medication and physical health monitoring was completed. A range of recognised psychological therapies were available.

• Reasonable adjustments were made for people with learning disabilities or autism. We saw that teams were flexible in location and times of appointments, assessments were delivered in different languages to meet patient needs and adjustments were made such as, the time of fire alarms to reduce the impact and distress of patients attending clinics.

• Teams worked with primary care community health services to improve physical health for adults with learning disabilities. Staff delivered training and supported GP surgeries in improving the uptake and quality of annual health checks and health action plans for patients with learning disabilities.

• Staff participated actively and regularly in research to review, evaluate and improve services for adults with learning disabilities or autism.

• Processes and systems were embedded to ensure reporting of incidents, completion of risk assessments and appropriate safeguarding of adults was in place.

Updated 20 December 2019

Our rating of this service went down. We rated it as requires improvement because:

• Clinical premises where patients were seen were not always safe and clean. Fire and environmental risk assessments were incomplete or out of date for a number of buildings.
• Staff did not complete and regularly review risk assessments for all patients. Risk management plans and crisis plans had not been completed or considered for all patients.
• Staff did not complete care plans for all patients. Care plans that were created are varied in terms of quality, they were not always holistic or recovery-oriented and did not consistently evidence involvement of patients or carers. Staff did not consistently use recognised rating scales to assess and record severity and outcomes for patients.
• Staff mandatory training compliance was low in a number of courses and there was no clear plan to drive improvement. Not all staff working with patients with dementia had received specific training in dementia. Staff at team level did not engage in clinical audit in order to evaluate the quality of care they provided.
• Methods of gaining feedback from patients and their families and carers varied between teams and some patients and carers we spoke with were unsure how they could give feedback.
• Whilst leaders had good oversight and understanding of areas for development within the service it was not always clear how they planned to make improvements. Staff at a team level did not have access to the service’s risk register.

However:

• Staff provided a range of treatments that were informed by best-practice guidance and suitable to the needs of the patients, including both mental and physical health needs.
• The teams included or had access to the full range of specialists required to meet the needs of the patients. Managers ensured that these staff received regular supervision and appraisal. Staff worked well together as a multidisciplinary team and with relevant services outside the organisation.
• Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients.
• The service was easy to access. Staff assessed and treated patients who required urgent care promptly. The criteria for referral to the service did not exclude people who would have benefitted from care.
• The service was well led and staff felt respected, supported and valued.

Updated 27 April 2018

• Risks to patients were assessed and mitigated. Staffing levels were calculated using a recognised staffing tool. Staff knew about different types of abuse and were confident about reporting concerns. Male and female accommodation was separated with the use of locked doors.
• People who were referred to the crisis assessment service had mental health assessments carried out. Physical health checks were offered to patients who were admitted to the crisis assessment unit. Staff had regular supervision and appraisals. Staff understood their roles and responsibilities in relation to the Mental Health Act and Mental Capacity Act. Audits were carried out to ensure section 136 documentation was completed correctly.
• Patients and carers said staff were kind and approachable. Staff supported patients appropriately. Agency staff were not used in the core service allowing for consistency of care.
• There was good evidence of detailed discharge planning taking place on the crisis assessment unit. The crisis assessment unit continued to have a positive impact on the length of stay and discharges on the acute wards, as well as a positive impact on readmissions to the trust within 28 days. Staff supported patients to access services which may benefit them. Complaints were logged and investigated. People who made a complaint were given feedback.
• Staff who worked in the crisis assessment service said they felt supported by senior staff members. The staff were aware of the trust’s values. Audits were carried out throughout the service to ensure a good rating was maintained.

Updated 20 December 2019

Our rating of this service stayed the same. We rated it as requires improvement because:

• The service did not always provide safe care. Staff and managers had not ensured that regular fire evacuation drills took place and that fire risk assessments were reviewed for all wards. The seclusion room at Parkside Lodge was not compliant with requirements because it did not have a two-way intercom.
• Staff at 2 and 3 Woodland Square had not ensured patient risk assessments were reviewed and updated on patients’ admission. They did not ensure that risks to patients’ physical health and well-being were assessed, managed and mitigated sufficiently. This included pressure care, bowel care and epilepsy care. Care plans did not contain all the information needed to ensure staff met patients’ needs to keep them safe and well.
• Patients’ care and treatment records did not contain all the information needed. Three patients had bed rail assessments that provided no information why a bed rail was required to keep patients’ safe. Two patient records did not contain mental capacity assessments and/or a record of a best interest meeting in relation to resuscitation and physical health.
• The service had not improved access to therapeutic activities or psychological therapies.
• 2 and 3 Woodland Square did not have adequate cooling systems in the clinic room to maintain a consistent recommended temperature range. Staff did not follow the trust’s policy on storage of medicines.
• The trust did not provide staff with training on learning disabilities or autism. There was no assurance they had the right skills or knowledge to meet patients’ needs effectively.
• Only 52% of eligible staff had received training in safeguarding children level three.

However:

• Staff at 2 and 3 Woodland Square undertook comprehensive medicines reconciliation processes prior to and on patients’ admission.
• Parkside Lodge had employed a speech and language therapist and they had completed communication assessments of all patients.
• Staff planned and managed discharge well. They worked with other services who provided aftercare.
• The service received 34 compliments in 12 months and carers provided positive feedback about how staff involved them in patients’ care and treatment.
• Staff felt respected, support and valued.

Updated 20 December 2019

Our rating of this service improved. We rated it as good because:

• The service provided safe care. The ward environments were safe and clean. The wards had enough nurses and doctors. Staff assessed and managed risk well. They minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding.
• Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
• The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received training, supervision and appraisal. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.
• Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
• Staff planned and managed discharge well and liaised with services that would provide aftercare. As a result, discharge was rarely delayed for other than a clinical reason.
• The service was well led and the governance processes ensured that ward procedures ran smoothly.

However:

• On one ward the junior doctor had not completed the annual physical health checks, however weekly physical checks using the Modified Early Warning Score tool had been completed, by the staff. The reason for this was the appointment of the current junior doctor had been after the due date for the annual checks.
• One patient had been identified as part of the admission process as needing a specialist bed and this had not been provided in a timely manner.
• A detained patient was refusing treatment in the form of an injection, while there were notes from the medical team about the injection being necessary to aid their recovery, and the staff were acting legally there was not an individual care plan or advanced decision on how to administer the injection with the use of restraint recording the patient’s wishes.

Updated 20 December 2019

Our rating of this service stayed the same. We rated it as good because:

• They provided a range of treatments that were informed by best-practice guidance and suitable to the needs of the patients. Staff engaged in clinical audit to evaluate the quality of care they provided.
• The teams included or had access to the full range of specialists required to meet the needs of the patients. Managers ensured that these staff received training, supervision and appraisal. Staff worked well together as a multidisciplinary team and with relevant services outside the organisation.
• Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
• The service was easy to access. Staff assessed and treated patients who required urgent care promptly and those who did not require urgent care did not wait too long to start treatment. The criteria for referral to the service did not exclude patients who would have benefitted from care.

However

• Clinical premises where patients received care were not always safe or clean. Staff could not be assured by accuracy of the equipment as they had not always been calibrated.
• Fire and environmental risk assessments were not all up to date and were scheduled to be completed.