Leeds and York Partnership NHS Foundation Trust

On this page

• 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 this assessment we rated this key question as good.

Example: At this assessment we rated well-led as good. Leaders had the skills, knowledge and experience to perform their roles. Staff knew and understood the provider’s vision and values and how they applied to the work of their team. Staff felt respected, supported and valued. Governance processes operated effectively. Performance and risk were managed well. Teams had access to the information they needed to provide safe and effective care. Staff collected analysed data about outcomes and performance. They used this to identify improvements

This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

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.

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

Staff had the opportunity to contribute to discussions about the strategy for the service during team meetings, daily ward meetings and during supervision and appraisal sessions.

Staff could explain how they were working to deliver high quality care within the budgets available. For example, introducing QR codes to enable young people to give feedback and ask questions of the multidisciplinary team more freely.

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.

Leaders had the skills, knowledge, and experience to perform their roles and had a good understanding of the services they managed. They could explain clearly how the teams were working to provide high quality care. There was a new head of operations for the whole service who had previously managed Mill Lodge only, and they were beginning to develop new practices based upon their experiences.

Leaders were visible in the service and approachable for patients and staff. Leadership development opportunities were available, including opportunities for staff to attend courses. Leaders in the service were open and honest as well as being compassionate with the young people in the service.

Staff felt respected, supported and valued. All staff we spoke with said they felt supported and valued at the service, with both management and ward staff saying they felt the staff team were happy. Staff told us the role could be stressful, but that they were well managed and supported by colleagues and senior staff.

The service fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff felt there was a positive culture at the service. No staff member we spoke to complained they had been the subject of discrimination or bullying.

We saw evidence that there were regular team meetings for staff to discuss any issues. All the staff we spoke with, told us that they were confident they could speak up if they had any concerns about the way they or the young people were treated. All staff we spoke to knew how to use the whistleblowing process.

All staff told us that they felt they could raise concerns to management about the service without fear of retribution.

There were daily opportunities for young people to feedback to the service any concerns or suggestions for change.

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.

Managers put reasonable adjustments in place for staff members to help them carry out their role. For example, managers explained how staff would be supported within the workplace including through flexible working agreements to account for personal circumstances, such as caring responsibilities and health issues.

Managers advised that reasonable adjustments could be put in place for staff members to help them carry out their role, based on their individual needs.

Staff received training in equality, diversity and inclusion as part of the service’s mandatory training.

The service did not always have clear responsibilities, roles, systems of accountability or good governance.

We did identify some concerns which governance systems in place had not identified or sufficiently addressed. This included management of fridge temperatures to ensure safe storage of medicines, physical health checks post-rapid tranquilisation, out of date supplement drinks for those at risk of malnutrition, recording errors relating to method of medicine administration, correct timing of medicine administration, and lack of essential fluid monitoring charts.

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

Staff had implemented recommendations from reviews of incidents, complaints and safeguarding alerts at the service.

Staff maintained and had access to a hospital wide risk register. It was clear that this was being used to effectively track current risks. Staff colour rated risks so higher ones could easily be seen and there was an effective system of reviewing these risks.

The service had plans for emergencies. These were contained within an accessible contingency management plan.

Staff had access to the equipment and information technology needed to do their work. The information technology infrastructure, including the telephone system, worked well and helped to improve the quality of care.

Team managers had access to information to support them with their management role. This included information on the performance of the service, staffing and patient care.

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.

Directorate leaders engaged with external stakeholders such as commissioners. They recognised the importance of these relationships and ensuring that they were being kept informed and involved.

We saw community care coordinators and other community partners taking part in ward round meetings and there was a close relationship with community services who would support young people post discharge.

Red Kite View and Mill Lodge had developed a carers peer support group giving the service an opportunity to engage with carers in a different environment and to provide input on various mental health subjects.

The service focused on continuous learning, innovation and improvement across the organisation and local system. They 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 consider opportunities for improvements and innovation and this led to changes. For example, the development of new multi-disciplinary team meeting procedures to encourage young people to engage with the process, and the development of a psychological strategy for the service.

A clinical nurse specialist post had also been created and recruited to, and the role of a carer as the lead for the carers peer support panel was under development.

Staff participated in national audits relevant to the service and learned from them. Wards participated in accreditation schemes relevant to the service and learned from them. For example, both wards at Red Kite View were members of quality network for inpatient CAMHS (QNIC). Mill Lodge was working towards that accreditation.