Leeds and York Partnership NHS Foundation Trust

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

This means we looked for evidence that the service met people’s needs. At our last assessment we rated this key question as good.

At this assessment the rating has remained good. This meant people’s needs were met through good organisation and delivery.

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.

Quality Statement Score: 3

The service made sure people were at the centre of their care and treatment choices and decided, in partnership with them, how to respond to any relevant changes in their needs.

Most patients said that care and treatment had been arranged around their individual needs and preferences.

Staff completed various nationally recognised tools and assessments when developing treatment plans. Staff supported, informed and involved people using the service and their families or carers.

During our tour of the wards, we saw that patients could personalise their bedrooms. Patients had lockers in which to securely store their possessions. There were multi-faith rooms available to patients.

We saw evidence of discharge planning and that patients were supported to move on with the next steps of their recovery journey.

Patients had a choice of food to meet the dietary requirements of religious and ethnic groups. The hospital offered a good variety of food options including Halal, Kosher, vegan, vegetarian, gluten-free and healthy options such as fresh fruit and vegetables.

Staff made adjustments for patients with specific needs such as mobility or communication issues.

Quality Statement Score: 3

The service understood the diverse health and care needs of people and their local communities, so care was joined-up, flexible and supported choice and continuity.

Patients and carers told us staff worked well in ensuring patients had access to joined-up care. Staff communicated with patients in a way that they could understand the different aspects of their mental and physical health care and treatment.

All staff we spoke with were passionate and committed to delivering good care. Staff provided one to ones and built good therapeutic relationships with patients.

Staff knew about and understood the standards for mixed gender accommodation and knew when to report a potential breach. Facilities and premises were appropriate for the services being delivered.

Managers had regular engagement with stakeholders and external services, inviting them to regular meetings and care programme approach meetings.

In preparation for discharge, staff worked closely with community teams, who were involved in discharge planning. Staff arranged for community teams to support patients on a period of leave who then fed back about how leave had gone.

The service identified whether housing or benefit arrangements were needed to be put in place to avoid delayed discharge. There were 1 social worker and 3 housing officers within the service who worked to support the discharge process, including arranging supported accommodation for patients who needed this. Managers confirmed they were recruiting a second social worker and that the vacancy was out to advert.

Managers kept a log of all patients who were clinically ready for discharge. We saw that wards had some delayed discharges, and in nearly all cases, this was due to external delay such as waiting for placements to be finalised.

Staff worked collaboratively with community- based social workers to plan and facilitate discharge and held multiagency discharge meetings to identify and action any barriers to discharge. These were attended by managers, clinicians, community teams, integrated care boards, housing teams, adult social care teams and third sector staff.

Quality Statement Score: 3

Staff provided appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

Patients told us staff provided information in a way they could clearly understand and that they knew how to request information regarding their care and treatment. Staff made sure people could access information on treatment, local services, their rights and how to complain. Wards had notice boards in patient areas with a variety of information to support this.

Feedback from carers about communication from staff was mixed with some carers telling us they did not always feel informed about their loved one’s condition. Some carers felt communication could be improved. One carer told us, “Communication has always been poor.” Another said, “If I want to hear anything from the nursing staff I’ve got to ask them.”

One of the IMHAs we spoke with fed back that that communication from ward managers was good but described communication from doctors as ‘sporadic”.

Leaders and staff told us people could be given information in a variety of ways to meet their needs. These included information in different languages, fonts, braille, easy read and via the use of flash cards. People had access to interpreters and signers if needed.

We saw evidence in care records that staff regularly reminded patients of their rights.

Staff issued patients with admission booklets when they were admitted to the ward which provided a range of information. A staff member would contact the patient’s family member or carer on admission subject to patient consent.

Staff maintained the confidentiality of information about patients. Care records showed that staff sought patients’ consent to share information and reviewed this regularly. Staff we spoke with understood the principles of data protection legislation.

At the time of inspection, information governance training compliance was above 85% on all wards. This training focussed on the secure management and handling of personal information and ensuring personal information was kept confidential.

Quality Statement Score: 3

The service made it easy for people to share feedback and ideas or raise complaints about their care, treatment and support. It involved them in decisions about their care and told them what had changed as a result.

Patients generally told us they felt listened to when they voiced their preferences or asked questions about their treatment or medicine. Patients had access to independent advocacy.

Carers, friends and families attended ward rounds and multidisciplinary team meetings where appropriate. Feedback from carers about their involvement in care and treatment decisions was generally poor. Some felt their views and wishes were valued, but others felt that staff had not always taken these into consideration.

The service investigated complaints made by people using the service. All complaints were managed by the trust’s PatientAdviceandLiaisonService (PALS). This service providedconfidentialadvice,support,andinformationtopatients,families,andcaregiverswithintheNHS.

During 2025 there had been a total of 41 complaints. Wards 1 and 5 at the Becklin Centre had the highest number of complaints with 14 and 13 respectively, whilst Ward 4 Newsam Centre had the lowest, with just 1 complaint. 81% of complaints were withdrawn, notupheldor not known. Thirteen percent of complaints were upheld or partially upheld.

Managers discussed complaints that had been investigated at Acute Service Risk Management Meetings and had oversight of anyactionsrequired. The top 3 themes from complaints were clinical care, admission and transfer issues and staff attitudes.For 2025 there were 17 actions resulting from either formal complaints orconcerns raised by patients or carers to CQC, all of which had been completed.

Staff we spoke with understood the policy on complaints and knew how to handle them. Patients could raise concerns with any member of the team, and they would try to resolve them as quickly as possible. Some patients fed back that they did not know how to make a complaint. However, we saw that information was readily available on how to raise a concern or make a complaint.

Staff were visible and available for people to speak to as and when needed. Staff were observed engaging with people.

IMHAs supported people in giving feedback to the service where they requested this. Care records specified whether people had IMHAs in place. Staff held regular “Your Views” meetings on the wards to obtain patient feedback, although some staff said these were not always well attended. Wards had ‘You said, we did’ boards, which set out requests from patients and action taken as a result.

There were mutual help meetings in place where patients could make suggestions or requests. Agenda items included changes to the food menu and requests for new activities.
 

Quality Statement Score: 3

The service made sure that everyone could access the care, support and treatment they need when they need it.

Carers that we spoke to told us that they could speak with staff and felt comfortable to do so.

Patients had access to a range of professionals including a dietician, psychologist, speech and language therapist, and an occupational therapist. Staff worked as part of a multidisciplinary team model where professionals worked collaboratively to deliver holistic care to all patients.

Staff told us that on admission should any reasonable adjustments to care and treatment be identified then these would be recorded and incorporated into patient's care plans, such as the need for a translator or any additional support needed for patients with a learning disability or physical mobility issues.

Staff worked collaboratively to facilitate safe discharges with a continuity of care when aftercare had been identified. The service ensured patients had appropriate support and access to services upon discharge. This included ensuring Section 117 aftercare arrangements were in place. They involved community teams in the care progress and ward round meetings in preparation for discharge. A specialist practitioner within the service monitored all out of area placements and attended MDTs to support with this.

Quality Statement Score: 3

The service actively sought out and listened to information about people who were most likely to experience inequality in experience or outcomes. It tailored care, support and treatment in response to this.

Patients’ human rights were protected; they were supported by staff who promoted equality and helped them overcome barriers to care.

We did not identify any barriers to care, support and treatment. The service complied with legal equality and human rights requirements, including avoiding discrimination. They had regard to the needs of patients with different protected characteristics and made reasonable adjustments to support equity in experience and outcomes.

A ward manager at the Becklin Centre described a planned piece of work around racism awareness. They told us they had identified several staff members who could lead on this and said they would link in with staff at the Newsam Centre to complete the work.

Staff told us they recognised people by their preferred pronouns and gender identity. Staff took patients' cultural or religious needs into account when providing care.

The trust had an ‘Improving Health Equity’ strategy in place. Restrictive practice data was split into age, race, sexual orientation etc.

Quality Statement Score: 3

The service supported people to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

Patients and carers told us they were involved in decisions about their future care and treatment. They were supported to access advocacy and were referred to healthcare professionals to manage their mental and physical healthcare needs.

The IMHAs we spoke with told us they attended ward rounds and observed clinicians explaining plans for treatment and discharge to patients, which they felt was done in a person-centred and respectful way.

Staff held regular care programme approach meetings involving family members and their wider network. Discharge planning started soon after admission, in line with best practice. The multidisciplinary team considered a range of possible outcomes for each patient based on their individual needs.

We saw evidence in care records that staff actively discussed and planned for discharge from the service. However, care records evidenced that some patients were still acutely unwell so discharge from the service was not currently appropriate.

Patients were involved in discharge planning meetings, and a detailed plan was developed with patients and carers.