Leeds and York Partnership NHS Foundation Trust

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• 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.

At this assessment we rated this key question requires improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

We found that fridge temperature checks were not always completed as per the trust policy, and on the general adolescent ward nursing staff had incorrectly documented an oral dose of rapid tranquilisation instead of an intramuscular dose for one patient. Physical observations were not always carried out after intramuscular rapid tranquilisation had been administered and this was in contradiction to the trust policy for post dose monitoring. At Red Kite View evening doses of antiepileptic medicines were not always given on time for one patient, and nasogastric fluid intake charts were not always completed.

We found that not all training courses met the trusts target for completion. We found high level interventions (Promoting Safer and Therapeutic Services) and breakaway skills, Life support training, paediatric essential life support and immediate life support were below 85% as required by the trust.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

There had been no serious incidents in the service in the 12 months preceding our assessment. We reviewed 3 incidents and found that all incidents had been investigated and reviewed by managers in clinical governance meetings and action taken to mitigate further incidents.

Staff told us they learnt from incidents through debriefs involving young people, discussions in handover meetings, weekly reflective practice sessions and from learning shared by the wider trust.

We saw that leaders ensured incidents were appropriately investigated and reported. We reviewed incident records and found that staff reported incidents correctly and managers investigated incidents when required.

There had been 14 incidents requiring a duty of candour response in the 12 months prior to assessment. These included 9 incidents of self-harm, 2 medicine errors, 1 accidental injury, 1 breach of confidential data and referring to physical health care. Staff understood the duty of candour and their requirement to be open and transparent and to give young people and families a full explanation if and when things went wrong.

The service’s referral and admission processes ensured that all essential information about the young person was received to determine if their needs could safely be met. There was evidence within the care records that information had been reviewed to ensure that staff had the necessary information ready to receive an admission of a young person to the ward, for example information about risks to self and others and physical health.

Staff involved all the necessary health and social care staff to ensure young people had continuity of safe care, both within the service and post-discharge. We could see that efforts were made to encourage the necessary professionals to attend multi-disciplinary meetings and that there was evidence of robust discharge plans being implemented which had led to safe and effective discharges of young people to the next stages of their treatment.

We saw carers attending meetings to discuss discharge, members of community health teams were also present, and all agreed collaboratively what support and plans would be in place before discharge.

Not all staff were trained in safeguarding. On the general adolescent ward compliance with safeguarding adults’ level 3 and safeguarding children level 3 training was only 58%. However, the overall compliance across the service was 81.75% due to much higher compliance on other wards. Two other courses safeguarding adults’ level 2 and safeguarding children level 2 were also below the trust target. However, only 4 members of staff had these courses as mandatory training and 2 members of staff who had been away from the workplace and unable to complete training in the required timeframe.

Managers had recognised the need to ensure staff were trained in safeguarding and measure were in place to ensure all staff were trained shortly after our assessment.

There were 139 safeguarding referrals made in the 12 months preceding our assessment, with 15 from Mill Lodge and 124 from Red Kite View.

Staff could give examples of how to protect young people from harassment and discrimination, including those with protected characteristics under the Equality Act. 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 and other people visiting the service.

Young people said they felt safe on the ward. It was clear that where related safety incidents took place, staff took appropriate action to protect all young people and to prevent further incidents.

We reviewed 7 risk assessments and care plans relating to young people at Red Kite View and 5 at Mill Lodge. Staff completed risk assessments for all young people and updated them when required. Risk assessments were tailored to the young person’s specific needs and correlated with their assessment. The care plans we reviewed were sufficiently detailed to inform staff how best to support people with complex health conditions. However, we found the care plans at Red Kite View to be more detailed and personalised than at Mill Lodge. For example, in one risk management plan we saw details regarding a mobile telephone being confiscated at night, but this was not also detailed in the young person’s care plan. In another we saw evidence a young person was using heat pads for a physical health reason, but this was also not recorded in the care plan. We were concerned this could mean that staff may not always be aware of essential information pertinent to patient care and treatment.

However, we found that staff involved young people in care planning and risk assessment, and this was evidenced within young people’s care documentation. Staff communicated with young people so that they understood their care and treatment, including finding effective ways to communicate with young people with communication difficulties. We saw the use of good communication tools for a young person with communication difficulties. Carers had a good understanding of the care plans and what should be happening to support their loved ones.

During the previous 12 months there had been 1445 incidences of restraint. At Red Kite View this related to 1229 restraints: 854 on the general adolescent unit and 375 on the PICU. At Mill Lodge there had been 186 restraints. Of this 1445, while restraints at Red Kite View were more frequent, we found that this did reflect the acuity of the young people being cared for there. This number also included low level restraints. Low level restraints are usually interventions where service users are guided physically.

Prone restraints were high, out of 47 prone restraints 2 were recorded at Mill Lodge, 22 on the general adolescent ward and 23 on the PICU. We spoke with young people who had been restrained, and they did not believe staff had used excessive force when they had been restrained.

Staff administered rapid tranquilisation on 72 occasions in the 12 months prior to our assessment. We reviewed incidents where rapid tranquilisation had been recorded, staff had attempted de-escalation and used rapid tranquilisation as a last result. We cross referenced these incidents and they had been recorded within the care records and handover briefings.

There had been 57 incidents of seclusion with 54 being on the PICU. We checked seclusion records and they were complete and evidenced that young people were kept in seclusion for the for the shortest period possible.

Staff enabled young people to give feedback on the service they received, for example, via community meetings or feedback forms. Young people felt able to feedback concerns. Staff also ensured that young people could access advocacy.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Staff did daily safety walks to assess the ward environment. We saw evidence of maintenance work being carried out because of issues identified during these checks.

Seclusion rooms allowed clear observation and two-way communication and had toilet facilities. However, on the day of our assessment the seclusion room did not have a clock visible to enable young people in seclusion to be orientated to the time of day.

Health and safety checks were carried out and were up to date; these included regular audits of ligature risks, fire safety equipment and procedures, portable appliance tests and staff alarm systems.

The ward layout allowed staff to observe all parts of ward and there were staff working throughout the wards who were able to observe the young people. There were potential ligature anchor points which staff had identified with risks being mitigated adequately. This was managed on an individual basis, such as through individual observations of young people.

Staff had easy access to alarms and young people had easy access to nurse call systems. Records showed that staff responded to incidents quickly, and staff said they felt well supported during incidents.

Clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly.

Staff establishment levels were set by the trust. Managers calculated and reviewed the number and grade of nurses, nursing assistants and healthcare assistants for each shift when planning rotas. The ward manager could adjust staffing levels according to the needs of the young people. Each location held daily safety huddles to assess staffing and consider any shortfalls.

There were enough staff to carry out physical interventions safely (for example, observations, restraint and seclusion), and staff had been trained to do so. There was also medical cover day and night and a doctor could attend the ward quickly in an emergency.

Staff vacancies were low. Mill Lodge had 2 nurse vacancies and Red Kite View had one nurse vacancy on the general adolescent ward and 2 health care assistant vacancies on the PICU. All of these were either advertised, appointed to or awaiting interview. Red Kite View had the highest staff sickness rate with the general adolescent ward reporting 9.87% and the PICU 6.78%. Miil Lodge reported 4.64% sickness over the same period.

We reviewed the shifts at both locations for a 3 week period prior to the on-site assessment. The use of agency staff was rare, and bank staff use was kept to a minimum. The service reported no activities or leave being cancelled due to staff shortages and all shifts were covered.

Staff were not up to date with all their mandatory training. The trust’s mandatory training target figure was 85%. At Mill Lodge only 71% of staff had completed high level interventions (Promoting Safer and Therapeutic Services) and breakaway skills. Life support training was also below the trust target with immediate life support at 76%, paediatric essential life support at 64% and paediatric immediate life support at 59%.

However, managers provided evidence that staff were booked on to courses and they ensured enough trained staff were present on each shift.

At Red Kite View on the general adolescent ward 73% of staff had completed high level interventions (Promoting Safer and Therapeutic Services) and breakaway skills. Life support training was also below the trust target with immediate life support at 50%.

On the PICU ward immediate life support training was at 64%.

Again, managers provided evidence that staff were booked on courses and ensured that trained staff were present on all shifts.

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 adhered to infection control principles, including handwashing. They told us that they washed their hands to prevent infection, and that personal protective equipment was available if required.

All ward areas were clean, had good furnishings and were well-maintained. Managers completed audits to ensure staff cleaned all areas when required to do so and bedding and other soft furnishings were replaced according to the trust’s policy. Staff made sure cleaning records were up-to-date, and the premises were clean. We reviewed cleaning rotas and spoke with housekeeping staff who were able to show us up to date and comprehensive records. During the assessment we saw continuous cleaning activity, and the ward was clean and tidy.

Staff did not consistently follow good practice in medicines management (that is, transport, storage, dispensing, administration, medicines reconciliation, recording, disposal, use of covert medication) in line with national guidance.

On the GAU ward at Red Kite View, there were ongoing issues with staff not recording temperatures daily to ensure medicines were being kept in the correct environment. Since July 2025, 19 dates had no temperatures recorded. Pharmacy staff had repeatedly reported these failings using the trust Datix system but stated that it was a constant problem with that particular ward. On the same ward we also found supplement drinks were out of date. These drinks were used under medical supervision for managing malnutrition, weight loss, or increased nutritional needs and we were concerned that young people may be given these drinks when they were no longer safe to be consumed.

Medicines reconciliations (a list of medicines a young person was taking prior to admission, compared to what is currently prescribed), was completed in a timely manner-generally within 24 hours. The electronic prescribing medication and administration (ePMA) system clearly showed pre-admission medicines compared to inpatient and discharge medicines. Staff stated overall that they preferred the electronic system to paper, as it was clearer and safer to administer.

However, at Red Kite View we did see an administration error where nursing staff had incorrectly documented an oral dose of rapid tranquilisation being administered, instead of an intramuscular dose. It was unclear if any action had been taken to ensure the young person received adequate monitoring given the method of administration was documented incorrectly.

When intramuscular injections had been administered, documentation was present in the nursing notes, and most incidents were reported using the Datix incident reporting system.

However, staff did not always review the effects of medication on patients’ physical health regularly and in line with NICE guidance. On the PICU at Red Kite View, physical observations were not always carried out for young people after receiving intramuscular rapid tranquilisation. One young person was receiving regular intramuscular rapid tranquilisation, in October 2025, 3 out of the 5 administrations given had no further physical observations documented.

We also found evening doses of antiepileptic medicines were not always given on time. It is vital for doses to be given at correct times to maintain seizure control and a consistent level of drug in the body.

At Red Kite View there were 4 young people who were being fed via a nasogastric tube. We could not find fluid intake charts for 2 of them. Nasogastric feeding fluid recording guidelines emphasize accurate documentation of intake, output, and safety checks to prevent complications like aspiration.

However, we found that medicines were stored securely on all wards. Clinical areas where medicines were stored were locked and not accessible without designated keys.

Emergency drugs and medical gases were kept in appropriate areas which were tamper-proof. Crash trolleys were checked daily by night nurses and expiry dates were entered into ‘Mykitcheck’: a trust system which highlighted when next checks were due and when items were due to expire.

Controlled drugs were monitored and checked daily by staff on both sites, and stock levels checked on assessment were all correct. Regular stock audits were evident which had been completed by pharmacy and nursing staff. However, at Mill Lodge it was noted that some young person’s own stock was not returned to pharmacy, when they were no longer present on the ward.

Pharmacy staff were present at both sites to ensure medicine stock levels were maintained at an appropriate level. Minimal patient own ordering was needed at Mill Lodge, but where this was dispensed it was kept together with the ward stock. At Red Kite View, patient own ordering was separated from general ward stock.