Leeds and York Partnership NHS Foundation Trust

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

This means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

At our last inspection we rated this key question good. At this inspection the rating has changed to requires improvement.

Requires Improvement: This meant the effectiveness of people’s care, treatment and support did not always achieve good outcomes or was inconsistent.

The service was in breach of Regulation 18 Staffing.

This service scored 58 (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: 1. We scored the service as 1. The evidence showed significant shortfalls. The service did not make sure people’s care and treatment was effective because they did not check and discuss people’s health, care, wellbeing and communication needs with them.

We reviewed 15 care records during the on-site inspection.

Staff completed a comprehensive mental health assessment of the patient in a timely manner at, or soon after, admission.

Staff assessed patients’ physical health needs in a timely manner after admission to the wards. A full physical examination, as well as a full set of bloods were part of the admission process by the ward doctors. We saw evidence of ongoing monitoring, in particular blood pressure and pulse were checked daily (more if required) and weight was checked weekly (again, more often if required).

Staff developed care plans that met the needs identified during assessment. Care plans were personalised, holistic and recovery oriented.

However, we were not assured that staff always updated care plans when necessary. We found that on Asket Croft, some care plans were in need of review due to the time that had passed since last review, and this had not been completed. Staff acknowledged this, and attributed the lack of updates to high levels of staff sickness and a recent serious incident on the ward. Staff had made plans to ensure these were updated and although some care plans were due for review, we did feel assured that staff understood care they provided to patients and that care plans generally reflected up-to-date information.

On Newsam Ward 5, we were unable to see a clear audit trail for when patients care plans were updated on the electronic patient record system. Although we found that care plan audits were taking place, the system relied upon staff emailing the person completing the audit to let them know care plans had been updated. We were unable to see emails for all care plans, and were concerned this was not a reliable system to audit the dates that care plans were updated. As the records system only indicated the date of last update and all the care plans had been updated on the ward during our inspection, on the evening of 10 March 2026, we were then unable to see previous dates.

We found examples on the records system, where the date of care plan reviews was available and showed monthly updates, but we were told this was not the normal procedure as it meant closing the care plan each time it was updated and opening a new one. It was unclear why the review system was used to evidence updates for risk assessments but was not used in the same way for care plans.

We found the care plan for one patient on Asket Croft with a significant leg wound did not show evidence on the records system of being updated since August 2025. Although we were assured this was being managed correctly, and tissue viability nurses were involved, we could not reliably see that the care plan had been updated . We also noted 2 patients on Newsam Ward 5, had gaps between updates of up to 6 months. We fed this back to the ward team at the end of our first day on site and received assurance updates had been completed.

We were concerned that a patient on Asket House who was at risk of absconding from the ward had no care plan in place to manage this risk. This was fed back to ward staff at the end of our first day on site and we received assurance this had been reviewed and actioned.

Following a data request for care plan audits, we found that although these were being completed monthly, they were not effective as they did not identify the issues we found during our inspection.

Quality Statement Score: 1. We scored the service as 1. The evidence showed significant shortfalls. The service did not plan and deliver people’s care and treatment with them. They did not follow legislation and current evidence-based good practice and standards.

Staff were experienced and qualified but did not always have the right skills and knowledge to meet the needs of the patient group. We did not see evidence of any specialist training in relation to rehabilitation in mental health and some mandatory training courses were low in compliance, including fire training, immediate life support and physical intervention training.

As part of our data request following inspection, we asked the trust to provide us with a summary of all specialist training relating to rehabilitation in mental health care undertaken by staff in the last 12 months, broken down by ward. We received a response from the trust that stated there were no requirements for this type of training.Therefore, we are unable to comment on specialist training staff may have undertaken in the 12 months preceding our inspection or whether staff were provided with opportunities to develop their skills and knowledge in this area.

Managers did not always provide staff with supervision (meetings to discuss case management, to reflect on and learn from practice, and for personal support and professional development) or appraisal of their work performance. Supervision and appraisal compliance was below the trust target of 85% on all wards. Supervision figures were as follows: Asket Croft –74%, Asket House – 60% and Newsam ward 5 – 80%. Appraisal figures were as follows: Asket Croft – 74% Asket House – 60% and Newsam ward 5 – 80%. Despite this, staff we spoke to told us they felt supported by their team and managers and that if they needed support, they could approach their manager at any time.

Managers ensured that staff had access to regular team meetings.

Managers provided new staff with appropriate induction, using the care certificate standards as the benchmark for healthcare assistants.

Staff provided a range of care and treatment interventions suitable for the patient group. The interventions were those recommended by, and delivered in line with, guidance from the National Institute for Health and Care Excellence (NICE). This included medication and psychological therapies, activities, training and work opportunities intended to help patients acquire living skills.

Staff ensured that patients had good access to physical healthcare, including access to specialists when needed. The National Early Warning Score (NEWS2) system was used on the ward to identify when a patient’s physical observations indicated medical intervention may be required. Patients requiring admission to an acute hospital were supported with this without undue delay.

Staff assessed and met patients’ needs for food and drink and for specialist nutrition and hydration.

Staff participated in clinical audit, benchmarking and quality improvement initiatives. However, we did find that the care plan audits and some medicines audits, although complete, were not effective in identifying concerns regarding updating care plans at regular intervals.

The teams all included, or had access to, the full range of specialists required to meet the needs of patients in the service. As well as doctors and nurses, the teams comprised of occupational therapists, psychologists and support workers. They also had access to pharmacists and speech and language therapists.

Managers dealt with poor staff performance promptly and effectively.

Mental Health Act

86% of staff had received training in the Mental Health Act.

Staff were trained in and had a good understanding of the Mental Health Act, the Code of Practice and the guiding principles.

Staff had easy access to administrative support and legal advice on implementation of the Mental Health Act and its Code of Practice. Staff knew who their Mental Health Act administrators were.

The provider had relevant policies and procedures that reflected the most recent guidance.

Staff had easy access to local Mental Health Act policies and procedures and to the Code of Practice.

Patients had easy access to information about independent mental health advocacy.

Staff explained to patients their rights under the Mental Health Act in a way that they could understand, repeated it as required and recorded that they had done it.

Staff ensured that patients were able to take Section 17 leave (permission for patients to leave hospital) when this has been granted.

Staff requested an opinion from a second opinion appointed doctor when necessary.

Staff stored copies of patients' detention papers and associated records (for example, Section 17 leave forms) correctly and so that they were available to all staff that needed access to them.

The service displayed a notice to tell informal patients that they could leave the ward freely.

Care plans referred to identified Section 117 aftercare services to be provided for those who had been subject to section 3 or equivalent Part 3 powers authorising admission to hospital for treatment (if applicable).

We requested the last Mental Health Act audit for each ward following our inspection. We did not receive this for Asket House. The audits we received for Asket Croft and Newsam Ward 5 were complete and allowed staff to ensure that the Mental Health Act was being applied correctly and there was evidence of learning from those audits.

Quality Statement Score: 3. We scored the service as 3. The evidence showed a good standard. The service worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

Staff held regular and effective multidisciplinary meetings. During our on-site visit we observed a multidisciplinary meeting on Asket Croft. We observed that the patient was involved in the meeting and was able to chair the meeting, if they felt comfortable with this. We saw the patient’s progress discussed alongside risks, goals and medication. The multidisciplinary team were present in the meeting, and all were able to give their point of view.

Staff shared information about patients at effective handover meetings within the team for example, shift to shift.

The teams had effective working relationships, including good handovers, with other relevant teams within the organisation such as care co-ordinators, community mental health teams, and the crisis team.

The teams had effective working relationships with teams outside the organisation such as the local authority, social services and GPs.

Quality Statement Score: 3. We scored the service as 3. The evidence showed a good standard. The service supported people to manage their health and wellbeing to maximise their independence, choice and control. The service supported people to live healthier lives and where possible, reduce their future needs for care and support.

Staff supported patients to live healthier lives. Examples included participation in smoking cessation schemes, healthy eating advice, managing cardiovascular risks, screening for cancer, and dealing with issues relating to substance misuse. The service had good links with local substance misuse services in the community and access to local gyms for exercise for those who were able to attend. There was some gym equipment on site for patients to access with support of staff. Healthy eating was encouraged and education around this was provided, for example a “fakeaway” evening where patients chose a takeaway style meal to cook in a healthier way. However, the lack of access to outdoor space for patients on Newsam Ward 5 meant that patients did not have access to fresh air and an outside space to exercise,

Ward activities helped promote a healthy lifestyle for patients, for example local area walking groups, sports activities and cooking healthy meals.

Quality Statement Score: 3. We scored the service as 3. The evidence showed a good standard. The service routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves.

Staff used recognised rating scales to assess and record severity and outcomes such as Health of the Nation Outcome Scales. Dependent on the stage of rehabilitation patients were at, this could mean small improvements over a longer length of time. This meant improvement was sometimes difficult to formally measure, but care plans and goal setting were used to record what the patient wanted to achieve and to set realistic timescales for this.

Quality Statement Score: 3. We scored the service as 3. The evidence showed a good standard. The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

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. We saw examples of this during our review of records, examples included decisions about future care placements with visits to new places facilitated by staff, options in treatment plans given to patients and choices around finances being supported by staff. Staff did this on a decision-specific basis with regard to significant decisions.

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