Leeds and York Partnership NHS Foundation Trust

On this page

• 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 our last assessment, we rated this key question good. At this assessment, the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was an increased risk that people could be harmed.

This service scored 50 (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 had a proactive and positive culture of safety based on openness and honesty, in which concerns about safety are listened to, safety events are investigated and reported thoroughly, and lessons are learned to continually identify and embed good practices.

Patients told us they felt safe on the wards. They said staff managed incidences of restraint in a safe way that had not resulted in them being harmed.

Staff described a culture of learning where they felt able to raise concerns and gave examples of how they had been treated and supported in a proactive way. Staff told us that learning from safety incidents was shared and they implemented this learning into their work practices.

Managers allocated patients a staff member at the start of each shift from whom they could seek advice, support and information to help them with their health, wellbeing and manage their own risks.

Staff and managers were able to demonstrate their understanding of the types of incidents that needed to be reported. Staff felt able to raise concerns about care and treatment freely and told us managers dealt with these well.

We reviewed a sample of incidents and saw that managers investigated these thoroughly, provided feedback to staff, and identified learning. Managers held huddles following incidents of restraint which enabled the team to identify immediate actions or learning.

Data provided by the trust showed that the service had seen a reduction in the total number of incidents from the previous year, by 6.11% from 3,484 in 2024 to 3,271 in 2025. Ward 5 was the only ward with a rise in total incidents of 22% from 2024, andward 1 had seen the biggest reduction of 29%.

The 2 female acute wards, Wards 1 and 5 at the Becklin Centre, accounted for 59% of all incidents. The largest number of incidents were self-harm (486), violence / assault (446), andclinical patient care (412).

Staff received de-briefs following incidents, underpinned by the Critical Incident Staff Support Pathway (CRISSP). This isa structured framework which provides immediate and ongoing psychological care following traumatic workplace events. It prioritises emotional safety through peer support, debriefing, and, when necessary, signposting to specialist mental health support.There were CRISSP and designated ‘people wellbeing leads’ within the trust who facilitated both group and individual debrief sessions.

There were a range of meetings in place to enable ward managers and leaders to discuss incidents and identify themes.

Staff told us they received lessons learned from investigating incidents, complaints and safeguarding concerns via emails, during team meetings and supervision.
Staff we spoke with knew what their responsibilities were under the duty of candour. They could provide examples of when they had provided apologies to patients when things had gone wrong.

Complaints from family members and people who used the service were investigated and resolved with actions put in place where required.

Quality Statement Score: 3

The service worked with people and partners to establish and maintain safe systems of care, in which safety is managed, monitored and assured. It ensured continuity of care, including when people move between different services.

The service’s referral and admission processes aimed to ensure that all essential information about people was received to determine if their needs could safely be met. Staff ensured they had information about risk, the Mental Health Act section the patient was being detained under, what their current situation and presentation was, their usual accommodation, their physical and sensory needs, and the predominant reason for the referral.

There was a capacity and flow team within the trust who gathered information about potential admissions and liaised with managers to determine whether an admission was appropriate. Some admissions were unplanned and there were staff available 24 hours a day to support admissions at nighttime or weekends. Managers held daily capacity meetings to coordinate admissions and discharges across the service.

Patients we spoke with told us that services communicated well with each other to ensure they had continuity of care.

Staff told us there were effective working relationships with other relevant teams, both within and outside the organisation. Staff said that people’s risks were shared between teams during handovers.

Staff could explain the pathway in and out of the service. Patients were admitted from a variety of settings including accident and emergency, crisis and home treatment teams, section 136 suites, out of area repatriations, and other mental health wards, as well as patients who were recalled from Community Treatment Orders. A Community Treatment Order enables patients to be discharged from hospital to receive psychiatric treatment while living in the community.

We saw evidence in care records that staff supported patients in accessing care and treatment from other healthcare professionals such as GPs, dentists, dieticians and speech and language therapists.

Staff involved all the necessary healthcare and social care services to ensure patients had continuity of safe care, both within the service and post-discharge.

Managers held weekly multi agency discharge meetings with representatives from housing, adult social care and the third sector, to discuss each patient including any barriers to discharge and required actions.

Despite close working relationships, delayed discharges remained at high levels within the service. Managers told us housing and social care challenges were a common barrier to discharge.

Quality Statement Score: 2

The service mostly worked with people to understand what being safe meant to them as well as with its partners on the best way to achieve this. The service concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect, and made sure we share concerns quickly and appropriately.

Patients felt supported by staff and that they could share any worries or concerns with them. Patients felt safe on the wards and had not experienced any abuse.

Staff received training on how to recognise and report abuse, appropriate for their role. Staff mostly kept up to date with their safeguarding training. Data showed that most safeguarding children and safeguarding adults training modules were above the trust target of 85%. However, there were some outliers, including Ward 1, the Becklin Centre: 61% for Safeguarding Children, Level 3, and Ward 4, the Becklin Centre: 71% for Safeguarding Adults and Safeguarding Children, Level 3.

Staff knew how to recognise adults and children at risk of or suffering harm and worked with other agencies to protect them. Staff followed clear procedures to keep children visiting the service safe. These visits were pre-arranged and took place in a room away from the wards.

Staff knew how to make a safeguarding referral and who to inform if they had concerns. They were able to identify different forms of abuse, and the signs associated with these. Staff attended regular meetings where important information and lessons learned were shared.

Staff and managers discussed individual patient safeguarding concerns during multidisciplinary team meetings and developed safeguarding plans where appropriate. Staff discussed safeguarding concerns during meetings and handovers to ensure all staff were aware.

During our tour of wards, we saw posters on patient noticeboards relating to safeguarding, including reporting abuse. There were safeguarding leads within the trust who provided advice and guidance to staff about potential safeguarding concerns.

The trust had safeguarding policies that staff could easily access.

The Newsam Centre, Ward 1 was mixed gender, and staff followed the trust’s policy on mixed gender accommodation. This included ensuring there was a female only lounge on the ward.

Staff had a good understanding of the Mental Capacity Act, in particular the five statutory principles. Training compliance for the Mental Capacity Act and Deprivation of Liberty Safeguards Level 2 was above 85% on all wards except for the Becklin Centre, Ward 4 (82%).

The trust had a policy on the Mental Capacity Act, including deprivation of liberty safeguards. Staff were aware of the policy and had access to it. Staff knew where to get advice from within the trust regarding the Mental Capacity Act, including deprivation of liberty safeguards.

Care records showed that staff took all practical steps to enable patients to make their own decisions.

For patients who might have impaired mental capacity, staff assessed and recorded capacity to consent appropriately. They did this on a decision-specific basis with regard to significant decisions. Managers gave examples of how capacity was considered and the processes that were followed within the service.

When patients lacked capacity, staff made decisions in their best interests, recognising the importance of the person’s wishes, feelings, culture and history.

Quality Statement Score: 3

The service worked with people to understand and manage risks by thinking holistically so that care meets their needs in a way that is safe and supportive and enables them to do the things that matter to them.

Patients told us they felt safe, and that staff supported them to manage risks. We reviewed 16 risk assessments during this assessment. Staff completed these for each patient on or soon after admission using a tool built into the trust’s care records system.

Care records showed that risk assessments were detailed, and that staff reviewed these regularly, including after any incident. However, 5 of the 16 risk assessments we reviewed did not contain evidence that staff involved patients in creating these. Nevertheless, staff we spoke with knew about the risks associated with each patient and acted to prevent or reduce them. Allocated workers familiarised themselves with up-to-date risk information about patients at the start of each shift. Managers also recorded important risk information about patients on safety huddle boards at the start of each shift. Staff used safety huddles to recognise triggers, anticipate potential incidents, and put steps in place to try and reduce these.

Staff discussed incidents regularly at a range of meetings. These included handovers, team meetings, ward rounds, multidisciplinary team meetings, and clinical governance meetings. Staff escalated concerns to managers when needed.

Managers had implemented daily safety huddles across all wards which had been embedded for a number of years. In September 2024 these were rolled out to the Newsam Centre ward 4. Managers described safety huddles as a multidisciplinary team meeting used to recognise patient’s triggers, anticipate potential incidents, and develop strategies to manage risks effectively. Staff spoke positively about these and said they enabled them to proactively manage potential risks.

At the Newsam Centre, Ward 4, managers had used safety huddles to focus on incidents of violence and aggression. Since implementing these, the ward had seen a significant reduction in incidents of violence and aggression by 30%, from an average of 2.7 to 1.9 incidents per week.

Staff were aware of guidance around restrictive practice and could provide examples of how they used the least restrictive option, for example regarding patients accessing items and Section 17 leave.

The service recorded and monitored incidents and discussed these during regular meetings. Incidents were scored in terms of level of severity and reviewed by managers, with actions put in place where necessary. Data provided by the trust showed that the service had seen a reduction in several reported incident categories from 2024 to 2025. These included self-harm (13%), violence (15%), security (55%), and medication (32%).

Blanket restrictions were only used when needed. Each ward manager recorded any restrictions on a blanket restriction register which they regularly reviewed. Banned and restricted items on the wards were appropriate for the risks associated with the patient group. These included access to alcohol, drugs, sharp items and lighters.

Quality Statement Score: 1

The service did not always detect and control potential risks in the care environment and make sure that the equipment, facilities and technology supported the delivery of safe care.

We reviewed the suicide prevention audits for each ward, which the service used to highlight areas of environmental risk. These were reviewed annually. These assessments generally highlighted areas of risk and appropriate mitigations that were in place to help reduce the risk level. However, on each of the wards at the Becklin Centre, there was a blind spot at the end of two corridors which were not documented on the suicide prevention audits or mitigated against. Some staff we spoke with were not aware of these blind spots. We raised this with the trust who confirmed that managers had reviewed the blind spots at the end of bedroom corridors and treatment rooms and had added these areas to the suicide prevention audit. They also briefed staff on all wards to ensure they were aware of the blind spots and ensured this was included on the ward induction for new starters. They also took steps to have mirrors installed into the inpatient areas and agreed to discuss the blind spots during the trust’s suicide prevention environments survey action group and clinical environment groups to consider the implementation of mirrors across all other inpatient areas.

We also found that a door within the quiet room on Ward 4 at the Newsam Centre had ligature points which was not identified on the risk assessment. A ligature point isa fixed, protruding, or accessible object that can be used to fasten a cord, rope, or bedding for hanging or self-harm. We raised this during the inspection and managers submitted a request to replace the door hinge and remove the ligature point. They also room locked the room as a precautionary measure, with all access being supervised until work could be completed. They also added the door to their suicide prevention environmental audit.

There was a seclusion room at the Newsam Centre. The seclusion room had a toilet and a clock and allowed clear observation. There was an intercom in place to enable two- way communication.

Patients generally told us that they felt safe on the ward and could speak with staff if they had any concerns. Staff were observed completing observations in communal areas and corridors depending on the location and observation level of each patient.

Managers completed regular walk rounds of the wards to check the environment and escalated any concerns to the estates team. Ward areas were clean, well maintained, well-furnished and fit for purpose.

All staff carried panic alarms and could respond promptly to alerts.

There were policies, procedures and risk assessments in place for health and safety and business continuity.

Managers attended an environmental audit action plan meeting monthly, to discuss ongoing risks and share updates.

There was also a trust wide clinical environments group and a ‘life cycle’ meeting attended by the facilities manager and external contractors to discuss ongoing work. At the time of inspection, renovation work was taking place at the Becklin Centre, Ward 1. This included installing furniture and other items that needed replacing.

Quality statement score: 1

The service made sure there are enough qualified, skilled and experienced people, who receive effective support, supervision and development and work together effectively to provide safe care that meets people’s individual needs.

Throughout our assessment, we observed that there were enough staff members on the wards to deliver safe care and treatment. Our discussions with staff evidenced they had the skills and experience to meet the patients' needs. We reviewed staffing data during the inspection and saw that managers had calculated the number and grade of nurses and healthcare assistants required. The number of nurses and healthcare assistants matched this number on all shifts.

Some patients told us there were sufficient staff to support them whereas others fed back that there were not enough staff to meet their needs.

Staff told us that staffing levels were sufficient to keep people safe. Managers told us that occasionally staff provided cross ward cover to ensure baseline staffing numbers were met. However, some staff felt they were often stretched or did not have time for therapeutic engagement with patients.

Managers monitored staffing via a staffing meeting which took place 3 times per week. The meetings aimed to ensure that there were enough staff or each shift and that the wards had the right skill mix to safely meet patients' needs.

Staff from neighbouring mental health trusts also picked up available shifts. Managers fed back that weekend and night shifts were easier to fill than daytime shifts.

There was a clear process of escalation in place to monitor and address any staffing concerns, with an allocated shift coordinator liaising with the clinical team manager who could then escalate to the modern matron if needed.

We asked several managers how they were assured that there were always enough staff to safely meet the needs of patients on the wards. They told us ward managers and matrons had oversight of staff rotas to ensure sufficient staff levels. They also said they were able to move staff from the older adults’ service within the trust if needed.

Managers used a recognised tool (MHOST) to determine staffing numbers. This was reviewed at least twice per year. They also completed an annual staffing review which looked at incidents, bank and agency usage, and sickness to determine whether staffing numbers were appropriate. The service had also created a promotional video which was advertised on social media to encourage people to apply to work within the service.

All staff received induction before starting work on the ward.
The service had recently increased baseline staffing numbers by 1 for both day and night shifts for all acute wards. We looked at staff rotas on the wards and found the planned numbers of staff for a particular shift matched the actual numbers on the day.

There were some vacancies at the time of inspection, but managers used NHS professionals’ bank staff to meet baseline numbers. Staff from neighbouring mental health trusts also picked up available shifts. Managers fed back that that weekend and night shifts were easier to fill than daytime shifts.

Staff did not always complete or keep up to date with their mandatory and required training. All ward-based staff were required to complete fire safety level 3 training. However, training compliance was significantly below the trust’s target of 85%: (Becklin Centre ward 1 (55%), Becklin Centre ward 3 (43%), Becklin Centre ward 4 (46%), Becklin Centre ward 5 (61%), Newsam Centre ward 1 (46%), Newsam Centre ward 4 (78%)). Data showed that between 2024 and 2025 there had been 22 fire related incidents reported at the Becklin Centre, with 9 reported at the Newsam Centre.

Otherwise most other training modules were over the trust’s target. The training modules were appropriate to meet the needs of the patient group and included infection control, information governance, personal safety with breakaway skills, and immediate and essential life support.

Managers ensured all staff had up to date disclosure and Barring Service (DBS) checks in place prior to starting work and monitored this with support from the human resources team. Managers also monitored when registered nurses were due to complete their revalidation and ensured this was completed.

The service monitored sickness levels on each ward and took steps to cover absences.

Quality Statement Score: 1

The service did not always assess and manage the risk of infection, detect and control the risk of it spreading and share any concerns with appropriate agencies promptly.

We identified concerns with how the service assessed and managed the risk of infection. 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. This included staff wearing watches, synthetic nails, rings, and bracelets. We were concerned about the infection risk this could pose to patients.

There were adequate supplies of personal protective equipment on the wards. Housekeepers visited the ward 7 days a week and followed a schedule of cleaning. This included cleaning of bedrooms and bathrooms. Staff could contact their estates and facilities teams for any additional cleaning. Cleaning staff completed a deep clean of each bedroom after patients were discharged.

Staff completed regular environmental and infection prevention and control audits and where areas of improvement had been identified, appropriate action plans were in place.

Staff demonstrated a good knowledge of infection prevention and control. Staff followed the trust’s waste disposal processes with clinical and non-clinical waste discarded and stored appropriately.

During our tour of clinic rooms, we found that staff had recorded that they cleaned equipment after each patient contact. Equipment was labelled to show when it was last cleaned.

There were monthly site meetings where managers could discuss or escalate any issues relating to environment or infection prevention and control concerns.

Quality Statement Score: 2

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning.

The service generally made sure that medicines and treatments are safe and meet people’s needs, capacities and preferences by enabling them to be involved in planning, including when changes happen.

Medicines administration records were clearly completed and where needed the appropriate Mental Health Act authorities for prescribing were in place.

While staff provided assurance that patients’ medicines were being reviewed regularly, this was not consistently reflected in the ward round documentation. In 5 out of 10 records, there was limited or no detail about medicines or physical health unless concerns had been raised by the patient. In addition, one entry incorrectly recorded the patient’s diagnosis on two occasions.

Patients prescribed medicines which require extra monitoring for example, lithium or clozapine received appropriate monitoring and physical health checks. For example, one patient who developed constipation related to clozapine received several reviews, and staff put suitable interventions in place to manage this. The pharmacy service had effective oversight of medicines prescribing on the ward, including management of high-risk medication such as clozapine and lithium.

Patients` physical health was checked following the use of rapid tranquilisation on the PICU ward and appropriate documentation follow up documentation was in place.

Patients with physical health conditions, including diabetes, received appropriate monitoring, with clear involvement from external healthcare professionals. Patients’ preferences were documented and taken into account when managing their condition.

Care plans were in place to support patients with long-term physical health conditions and their mental health medicines. However, medicine-related information was not always detailed or up to date.

Records did not consistently explain why when required medicines were given, whether they were effective, or what de-escalation techniques had been tried first. Some entries were also inconsistent with other records. For example, lorazepam was recorded as being given for agitation when notes at the time described the patient as calm or relaxed.

Observations of staff administering medicines to patients showed this was carried out in a person-centred manner whilst treating the patient with dignity.

Medicines, including controlled drugs, were handled safely and any issues identified were addressed. However, storage was not always in line with trust policy, with inconsistent fridge temperature checks, missing opening or expiry dates on some medicines.

The pharmacy medicine governance process documented systems for incident reporting and learning. Monthly operational meetings enabled the team to review incidents and share learning, which was then disseminated through local team meetings.