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 our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant the service was consistently managed and well-led.

This service scored 62 (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

We have a shared vision, strategy and culture that is based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding and meeting the needs of people and our communities.

The trust had a 5-year strategy in place which ran from 2025 to 2030. The strategy was titled “Improving the health and lives of the communities we serve”. Staff we spoke with understood the strategy and the trust’s core values of integrity, keeping it simple, and caring. Staff and leaders were able to give examples and anecdotal evidence of how they adhered to these values and implemented them into their daily roles. Staff were committed to the service and spoke passionately about the patients they cared for.

Staff we spoke with were generally happy and motivated, and felt able to raise concerns. Most staff told us they felt there was a positive culture within the service and the wider trust.

Managers ensured staff completed their required training in relation to equality, diversity and inclusion. Managers ensured that they recruited people with the same vision and values who could support with the development of the service.

Quality Statement Score: 3

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embody the culture and values of their workforce and organisation. They had the skills, knowledge, experience and credibility to lead effectively and did so with integrity, openness and honesty.

The service followed organisational processes to recruit managers and leaders with support from human resources. This included ensuring the relevant pre-employment checks were completed.

Managers could clearly describe their function and the roles and accountability of others within the service.

Staff knew who the managers and senior leaders were within the service and the wider trust. Most staff felt listened to and supported by their managers to undertake their roles although some staff felt senior leaders were not always responsive to their concerns.

Leaders were visible in the service and approachable for patients and staff. We heard how senior leaders attended the wards to engage with staff and patients.
 

Staff said that managers within the service recognised success. Staff further added that they could suggest new ideas and could raise challenges to their seniors. Staff generally described an open-door policy.

Managers monitored staff morale through daily handovers, debriefs, team meetings and during supervision sessions. Managers encouraged staff to raise their concerns or ideas for improvement and provided feedback on decisions made in response to them.

There were regular meetings on the wards which allowed managers to hear and engage with staff who wished to raise issues; facilitate debriefs and collaboratively put plans in place for improvement.

Leadership development opportunities were available, including opportunities for staff not currently in a management role. Opportunities were shared by managers and centrally by the communications team. Staff could complete leadership courses. There were a range of training and courses available to all staff which focussed specifically on development and career progression.

Quality Statement Score: 3

The service created a positive culture where people feel that they can speak up and that their voice will be heard.

Patients and carers had opportunities to give feedback on the service they received in a manner that reflected their individual needs. Patients and carers were involved in decision-making about changes to the service.

Staff and managers felt able to raise concerns without fear of reprisals. They knew how to access the trust's whistleblowing policy and information about the freedom to speak up guardian on the intranet.

There was a nominated freedom to speak up champion who staff could approach to support them in raising concerns. Managers promoted the freedom to speak up process within the service and reminded staff that they could contact the freedom to speak up guardian at any time.

Managers described how they trust used the NHS England Learning Culture and Leadership Framework, which was delivered through the Culture and Leadership Programme. This programme aims to foster a compassionate, inclusive, and collective leadership style. They told us they continually reviewed the culture of the organisation and had developed an action plan to do so.
The whistleblowing policy was available on the trust’s intranet. Contact details for the Care Quality Commission were displayed in ward areas as another avenue for patients and staff to raise concerns.

Quality Statement Score: 3

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

Staff said they felt managers were respectful of diversity. They completed occupational health reviews and made reasonable adjustments for staff where appropriate. Managers described how they aimed to ensure a diverse workforce.

Staff told us respect and valuing diversity was an important part of their role, and that they respected patients' religious and spiritual needs. Staff completed diversity and inclusion training annually.

Staff told us that people were able to apply to work flexible hours to take personal circumstances into account such as caring responsibilities or health issues. Some staff within the service were already accessing flexible working arrangements.

During the previous 18 months, the Trust had implemented Cultural Competency and Humility Training (CCHT) which was informed by trust-wide diagnostic work and priorities identified through the Civility and Respect Task and Finish Group.

The Becklin Centre, ward 4 had delivered 3 targeted sessions between February and March 2025, with 22 out of 30 staff attending these. The program focused on embedding practical behavioral changes, including improving cultural understanding, addressing bias, and strengthening inclusive practice within both team dynamics and patient care.
Managers told us this program had a positive impact. Post-session evaluations saw improved staff confidence, increased cultural awareness, and enhanced ability to address challenges arising from differences.

Quality Statement Score: 1

There were not always clear responsibilities, roles, systems of accountability and good governance to manage and deliver good quality, sustainable care, treatment and support. Managers did not always act on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

We found that managers had not taken appropriate steps to ensure staff were adhering to infection prevention and control standards by being bare below the elbows. Managers had also not identified or taken action to address delays in the completion of physical health assessments.

Whilst there were systems of governance in place to manage different aspects of the service these were not always effective. Managers and leaders had not taken appropriate steps to address issues with mandatory fire safety training compliance. Additionally, 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. Whilst there were care plan and risk assessment audits in place, we found that most care plans were generic and lack evidence of patient involvement, we were concerned that steps had not been taken to address this.

Staff participated in audits which were effective in identifying areas for improvement and acted upon these. Staff received information governance training and maintained patient confidentiality. Staff worked in partnership with other teams and services to ensure patients received high quality care and treatment.

Managers maintained and had access to the risk register. Staff at ward level could escalate concerns when required. Current risks included ligature anchor points, a recent safety incident, and the location of safes on wards 1 and 5 at the Becklin Centre. Each risk had controls and actions in place to mitigate against each risk, with regular reviews taking place.

We reviewed a sample of governance meeting minutes. These were attended by a range of staff and leaders. Key performance indicators and monthly audit processes were in place to help give oversight of the service. There were clear agendas for the various meetings that took place to ensure that staff and managers discussed all information relevant to the service.

Staff generally had access to the equipment and information technology needed to do their work, however staff feedback about the current electronic records system was mixed. Some staff fed back that the system was time-consuming and difficult to navigate. Some staff also told us that the internet was slow. We also found this to be the case during our review of care records.

Staff adhered to legislation and knew how to deal with complaints and reported incidents and safeguarding concerns. Managers shared lessons learned from investigating complaints, incidents and safeguarding issues.

There was a business continuity plan which included details of who to contact and what steps to take if and when an emergency arose. Managers described how they revisited the plan with staff during team meetings each quarter, and said new starters were given an overview of the plan during induction.

Staff participated in clinical audits which provided assurance, and staff acted on the findings accordingly, with action plans being developed where needed. Managers reviewed audit findings and action plans regularly

Staff understood the arrangements for working with internal and external teams and organisations, to meet the needs of the patients.

Staff submitted data and notifications to external bodies when needed. These included safeguarding referrals to the local authority and statutory notifications to CQC.

Quality Statement Score: 3

The service understood it’s duty to collaborate and work in partnership, so our services work seamlessly for people. Staff and leaders shared information and learning with partners and collaborate for improvement.

Managers described good working relationships with a range of external stakeholders. These included the neighbouring trusts, the local authority, substance misuse services, and supported living services. The service had links with other teams within the trust including community mental health teams.

Staff invited family members and external professionals to meetings so they could discuss any issues and receive any updates about their patient's / family member's care and treatment.

The trust had processes including care programme approach meetings, discharge meetings and ward rounds to ensure all relevant partners were involved in patients’ care. A ward manager described how they had worked with other agencies to facilitate a discharge to a supported living service with a neighbouring trust and work they had done to ensure an effective handover of care.

However, one of the IMHAs we spoke with told us that whilst they were invited to care programme approach meetings, they were not invited to ward rounds. They felt this was due to these being held ad hoc each day, without a timetable.

Staff had access to regular team meetings on the wards. They offered a forum for staff to propose, exchange and discuss ideas in terms of good practice.

Patients and staff could meet with members of the trust’s senior leadership team and commissioners to give feedback, and managers confirmed that senior leaders completed walk arounds on the wards.

Staff could attend reflective practice sessions facilitated by the psychology department.

Quality Statement Score: 3

The service focussed on continuous learning, innovation and improvement across our organisation and the local system. It encouraged creative ways of delivering equality of experience, outcome and quality of life for people. The service contributed to safe, effective practice and research.

The service participated in the culture of care programme. This is an NHS national programme and set of standards designed to improve inpatient mental health, learning disability, and autism services. The service was enrolled on the Culture of Care programme which is an NHS England initiative aimed at transforming the culture of inpatient mental health, learning disability, and autism wards.

Ward 5 was assigned the Quality Improvement workstream as part of the Culture of Care initiative when the pilot programme launched in 2024. A dedicated project group wasestablishedto explore potential change ideas, consider which interventions would have the greatest impact on the ward environment and patient experience, anddeterminehow these improvements could be effectively implemented.

As part of the Quality Improvement workstream, the project group, led by the Ward Manager, attended monthly meetings that brought together quality improvement teams from across the organisation. These sessionsprovidedan opportunity to share learning,showcaseinnovations, and exchange ideas to strengthen service improvement initiatives.

In addition, the project groups were invited to attend quarterly Learning Events, where staff connected with colleagues from other trusts across the country. These events enabled the sharing of best practice, collaborative learning, and mutual support to further enhance the quality of services delivered.

Ward 1 at the Becklin centre were assigned The Staff Care Development strand of the Culture of Care Programme, which aimed to support inpatient staff to develop cultures and systems that enabled everyone on the ward to feel safe and cared for. This was implemented through site visits, focus groups, skills-basedtrainingand coaching.

The service was in the process of reviewing its clinical inpatient model. Staff were involved in this review which included review meetings and process mapping. Managers described how the review aimed to assess the patient journey from admission to discharge, identifying any changes needed to improve patient care.

Other innovations included a thematic review into restrictive practice and the use of rapid tranquilisation with involvement from the pharmacy team and a dedicated task and finish group.

Following a rise in drug-related incidents in 2024 the service teamed up with West Yorkshire Police and City Group Security who brought in the Drug Detection Dogs to the Becklin Centre and Newsam Centre. This aimed to promote a zero-tolerance approach to drug use and a commitment to providing a safe environment. Managers confirmed they had continued to complete the environmental searchesmonthly.

The service, and wider trust was in the process of looking at the use of artificial intelligence (AI) and how this could benefit both staff and patients. This included using AI to record meetings and summarise notes. Managers had implemented a working group in place to complete the work, ensuring AI could be used reliably and effectively.