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 inspection we rated this key question requires improvement. At this inspection the rating has remained requires improvement.

Requires improvement: This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of regulation 12 safe care and treatment, Regulation 18 staffing and regulation 15, premises and equipment.

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. We scored the service as 3. The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

There were three incidents whereby a learning response was commissioned in line with the Trust’s Patient Safety Incident Response Framework (PSIRF) policy in the 12 months preceding the inspection. Due to the low number of serious incidents, there were no themes or trends identified. Staff told us that when they reported incidents, they received feedback in several ways including via team meetings, email, and during supervision.

We found that staff had a good understanding of the duty of candour and gave patients and their families an apology and an explanation when things went wrong. We saw there had been 4 incidents that met the duty of candour threshold in the 12 months preceding our inspection. Debriefs were carried out and support was offered to staff following serious incidents and staff told us that they felt this was beneficial and supportive.

Staff were able to tell us about changes made because of learning from incidents. Examples of learning from incidents included conducting pre-leave check-in conversations with patients and developing guidance for staff regarding patients socialising in each others bedrooms, this looked at the risks and benefits of allowing patients to socialise in bedrooms and developing a ward approach to this.

Quality Statement Score:

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The services’ referral and admission processes ensured that all essential information about the patient was received to determine if their needs could safely be met. We reviewed 15 patient records whilst on site and found that a thorough risk assessment was always completed. They detailed risks both to and from the patient which were clearly gathered at the point of admission into the service to ensure staff had an overview of the needs of the patient.

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. We saw that appropriate professionals were invited to attend meetings about the patient’s care on the ward and in the community, as well as being involved in their discharge plans.

Quality Statement Score: 1. We scored the service as 1. The evidence showed significant shortfalls. The service did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. They did not share concerns quickly and appropriately.

Although staff knew how to identify safeguarding concerns and actively sought advice from the trust safeguarding team when concerns were noted, we could not see that advice from the safeguarding team was consistently followed. Following our on-site inspection, we requested a summary of the last 5 safeguarding referrals for each ward with outcome details if known. There were no safeguarding concerns submitted relating to Asket House, there were 5 provided for Asket Croft and 3 for Newsam Ward 5. In 7 of the 8 cases reviewed, safeguarding contact forms were completed and appropriate advice documented. However, there was no recorded evidence in clinical records that the recommended referrals to the local authority were actioned, as advised by a trust Safeguarding Specialist Practitioner. The trust review looked at the last 12 months prior to our inspection and highlighted a significant gap in safeguarding practice and adherence to statutory duties under the Care Act 2014.

Of the 3 wards, Asket House and Newsam Ward 5 had 1 blanket restriction each noted on their blanket restriction registers. However, during our walk around on Newsam ward 5, it was noted that many doors had to be unlocked before entering, this included the therapeutic kitchen, one of the main bathrooms, the door to the garden and the activity room. We did not see evidence of these being noted on the blanket restrictions register, nor did we see individual risk assessments to note why patients who weren’t at risk could not have access to these rooms on an individual basis. Blanket restrictions were all in effect due to environmental concerns within those areas. The restrictions had been in place for some time with no resolutions to the originating issues. On Asket House the multi-faith room door was kept locked, this was due to awaiting a part for the door to ensure clear lines of site to the room and this had been on the register since 2024. On Newsam ward 5 the door to the garden was locked as this was down a flight of stairs and staff could not observe patients when outside. We saw evidence that these restrictions were reviewed on a regular basis, but had not been resolved and we could not see any evidence of plans to resolve in the near future. This was outside of the control of ward staff who required remedial actions to be undertaken by the estates team. We also noted that one of the main bathrooms on Newsam Ward 5 was permanently locked due to a risk within the environment. This was not noted on the blanket restrictions register for the ward and this issue was ongoing at the time of the inspection without resolution.

However, staff compliance with training in adults and children’s safeguarding level 3 was good with no ward falling below 75% compliance in any of the 6 training courses. Staff we spoke to could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act. Staff knew how to identify adults and children at risk of, or suffering, significant harm and whilst did seek support from the specialist safeguarding team when they identified a concern, they could not be assured they always followed that advice.

Staff followed safe procedures for children visiting the inpatient service.

Staff used restraint only as a last resort. We requested figures for the use of restraint in the 6 months preceding our on-site inspection. We were told that no restraint had been used on any of the 3 wards in this timeframe.

Mental Capacity Act

Overall, 85% of staff had had training in the Mental Capacity Act with all wards above 80%.

Staff had a good understanding of the Mental Capacity Act, in particular the five statutory principles

There were 2 deprivation of liberty safeguards applications made in the last 12 months prior to our inspection to protect people without capacity to make decisions about their own care.

The provider 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 provider regarding the Mental Capacity Act, including deprivation of liberty safeguards.

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.

When patients lacked capacity, staff generally made decisions in their best interests, recognising the importance of the person’s wishes, feelings, culture and history. However, we did find one example on Asket Croft where plans were made to hold a best interest meeting due to a safeguarding concern, but when records were reviewed, there was no evidence a best interest meeting ever took place. However, we did see evidence that staff continued to have ongoing discussions around the complex case and sought to ensure the patient was safeguarded from abuse.

Staff made deprivation of liberty safeguards applications when required and monitored the progress of applications to supervisory bodies. Out of the 2 deprivation of liberty safeguards applications made, 1 was awaiting further authorisation and staff were aware of this. CQC were notified of both applications.

Quality Statement Score: 3. We scored the service as 3. The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. Staff assessed and managed risks to patients and themselves well and followed best practice in anticipating, de-escalating and managing challenging behaviour. Staff used restraint only after attempts at de-escalation had failed. The ward staff participated in the provider’s restrictive interventions reduction programme. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We reviewed 15 risk assessments during the on-site inspection.

There were no episodes of restraint to review and no use of rapid tranquilisation or seclusion.

Staff involved patients in care planning and risk assessment, and we were able to see evidence of patient voice in most risk assessments we reviewed. 9 out of 11 patients told us they were aware of their risk assessment and care plan, some told us they were given a copy, whilst some told us they had not been offered a copy or did not want a copy. We observed a multidisciplinary meeting on Asket Croft, and found that the patient was fully involved, able to ask questions and lead on certain aspects of the meeting. We observed that professionals listened and took on board the patient’s opinions in this meeting.

Staff communicated with patients so that they understood their care and treatment, including finding effective ways to communicate with patients with communication difficulties.

Staff enabled patients to give feedback on the service they received (for example, via surveys or community meetings).

Staff ensured that patients could access advocacy.

Quality Statement Score: 2. We scored the service as 2. The evidence showed some shortfalls. The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

We found that many areas of the ward required maintenance, including chipped paint in patient bedrooms, graffiti on bedroom walls that patients told us had been there for some time, no running water to the sink in 1 bedroom, a blocked sink in 1 bedroom and a blocked toilet in the main bathroom that was overflowing. This meant that patients were being cared for in an environment that was not well maintained.

In addition, fire risk assessments for all 3 wards had not been updated in line with the trust’s expectations. Although it is not mandated for these to be completed annually, the fire risk assessment document indicated they should be reviewed in 12 months' time. At the time of our inspection these plans were all over 12 months old. This was despite Asket Croft being rated as a “major risk” in terms of fire safety in the fire risk assessment completed 19 December 2024.

Although ward layout did not always allow staff to observe all parts of ward, mitigations were in place. For example, parabolic mirrors to mitigate blind spots and patient observations pertinent to the level of risk the patients posed to either themselves or others.

Staff had mitigated the risks of potential ligature anchor points adequately and documented these in the suicide prevention environmental plan.

The ward complied with guidance on eliminating mixed-sex accommodation. Both Asket House and Asket Croft were mixed-sex wards. Male and female bedrooms were separated, there was a separate female lounge and bedrooms had ensuite facilities.

Staff had easy access to alarms and patients had easy access to nurse call systems.

Clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly. However, during our check of the emergency bag on Asket Croft, we found that one intravenous needle had expired. The emergency bag was sealed unless used and although staff checked the seal was in place, this piece of equipment inside the bag was not in date. Audits of the clinic room or emergency bag checks had not identified this issue.

Quality Statement Score: 1. We scored the service as 1. The evidence showed significant shortfalls. The service did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

Staffing levels were adequate across all 3 wards, with minimal vacancies. Sickness rates for Asket House and Asket Croft were high over the 12 months preceding our inspection at 13% and 16% respectively. There had historically been a pattern of staff being moved to the rehabilitation wards from wards with a higher acuity due to long term physical health issues and this accounted for some of the higher sickness levels within the service. However, turnover in the service was low with only one leaver 1 across all 3 wards in the 12 months prior to our inspection.

When necessary, managers deployed agency and bank nursing staff to maintain safe staffing levels. Agency staff were not generally used within the service, with less than 1% of shifts being staffed by agency for the 6 months prior to our inspection. Bank staff were used, and accounted for just over 15% of staffing, therefore meaning most staff were permanent and familiar to patients. When agency and bank nursing staff were used, those staff received an induction and were familiar with the ward.

Managers had calculated the number and grade of nurses and healthcare assistants required. At the most recent staffing review, it was noted that Asket House was operating with 2 staff on each shift (one qualified and one support staff). However, this was below the agreed establishment for this ward which was 3 staff during the day and 2 at night. Information provided told us that this number had been decreased during COVID-19 and never re increased, therefore the staffing review had recommended that the ward start working at its required establishment to benefit patient experience. It was unclear why this number had never been increased post COVID-19 and why this had not been recognised at subsequent staffing reviews.

The ward manager could adjust staffing levels daily to take account of case mix.

A qualified nurse was present on the wards at all times.

Staffing levels allowed patients to have regular one-to-one time with their named nurse. Although we heard from staff on Asket House that this could be difficult to manage with only 2 staff on duty. However, other members of the multidisciplinary team were on site during core hours and some evenings and weekends to support with this.

Staff shortages rarely resulted in staff cancelling escorted leave or ward activities.

There were enough staff on duty on Asket Croft and Newsam Ward 5 to carry out physical interventions safely. We were concerned this would not be the case on Asket House as only 2 staff were on each shift, but restraint had not been used in the 12 months preceding our inspection and we would not expect to see this routinely used in a rehabilitation setting.

Staff were not always up to date with appropriate mandatory training. Staff were trained at Asket House and Asket Croft in lower-level physical interventions, where as staff at Newsam Ward 5 were trained in higher level physical interventions due to the complex nature of their patients and being the initial stage of rehabilitation for most of their patients. However, training levels were low across all 3 wards for physical interventions. Asket Croft had only 48% compliance, Asket House had 65% and Newsam Ward 5 having 71% compliance.

We found the following courses were below the Trust expected compliance rate of 85%. Fire training level 3, (Asket House – 65%, Asket Croft – 60%, Newsam Ward 5 – 76%). Immediate Life Support (Asket House – 64%, Asket Croft – 67%). Physical intervention training (Asket House – 65% (Low level), Asket croft – 48% (Low level), )Newsam ward 5 – 71% (high level)

The training provided to staff was appropriate for the patient group using the service.

There was adequate medical cover day and night and a doctor could attend the wards quickly in an emergency.

Quality Statement Score: 1. We scored the service as 1. The evidence showed significant shortfalls. The service did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

Ward areas were not clean. Whilst we found minor environmental issues on Asket House and Asket Croft, such as some small areas of chipped paint and stains on furniture, we found that Newsam Ward 5 was in a poor state of cleanliness. The ward areas were not clean when we visited during our on-site inspection or when we subsequently returned on 15 March as part of our well led inspection of the trust. We found that many areas of the ward required maintenance to enable good infection prevention and control, including chipped paint in patient bedrooms, no running water to the sink in 1 bedroom, a blocked sink in 1 bedroom and a blocked toilet in the main bathroom that was overflowing. We emailed the trust following our initial on-site inspection and raised immediate concerns regarding a bedroom which appeared to contain a black substance, we were unsure what this was. This had been raised by staff to the estates team the previous month, but no action had been taken. We asked the trust to respond to our concerns within 24 hours with an explanation of what action had been taken. We were told the patient was moved from the bedroom and that the bedroom would not be used until the issue was resolved. We later received a further update that actions taken included treatment of all potential mould areas, a full redecoration, installation of new flooring, and specialist cleaning of the window.

Cleaning records were up to date but areas of the ward were visibly unclean. It was often noted that patients had refused cleaning staff entry to their bedrooms. We did not see evidence that this was then discussed with ward staff and revisited to ensure patient bedrooms were effectively and regularly cleaned.

3. We scored the service as 3. The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

Medicines administration records were clearly completedandwhere needed theappropriate MentalHealth Act authorities for prescribing were in place. We saw that patients were engaged in discussions about their medicines, for example when treatments changed. Patients could speak with the pharmacy team about their medicines and leaflets about commonly used mental health medicines were provided. Medicines needs were considered in patients care plans.

On occasion medicines information within patients’ care plans was missing or overdue for review. For example, a care plan for an informal patient still referred to an earlier T2 form (a Mental Health Act form to authorise treatment), and another lacked clear information about clozapine. A recent check (Asket House December 2025) showed similar areas for improvement, however, these issues remained at our inspection. Individual actions were clearly recorded so that these could be promptly addressed, exemplar and good practice was also captured.

Medicines self-administration was supported when safe andappropriate, to promote patients’ independence. We saw that patients’ medicines needs were reviewed at 3-weekly multidisciplinary (MDT) meetings, and a self-reporting tool was used to monitor for potential side effects of antipsychotic medicines. The use of ‘when required’ medicines was kept under review, but we saw one example where a ‘when required’ medicine had not been used for several months but consideration of deprescribing was not documented. We discussed this with the consultant and were assured prescribing would be reviewed. We did not see any patients prescribed high dose antipsychotics (HDAT). The trust completed weekly prescription chart checks to help ensure that prescribers were alerted to any HDAT prescribing, in order that the appropriate safeguards could be put in place. The audit also provided oversight for medicines self-administration, and we saw examples where record keeping gaps had been identified and shared with ward staff to support improvement.

At the time of the on-site inspection the pharmacy team were reviewing and developing how they worked with the ward MDT. On Newsam Ward 5, proactive specialist mental health pharmacy support for medicines optimisation was provided through twice weekly ‘board rounds’. Pharmacist support to Asket House and Asket Croft was largely remote but there were plans to establish a fortnightly prescribing meeting with resident doctors to discuss patients’ medicines. Work was similarly ongoing to develop pharmacy support around patient discharge, and supporting safe medicines use when patients moved between services. Appropriate arrangements were in place for the supply of medicines when patients took leave from the wards.

Medicines including controlled drugs were generally safely stored. However, we did find examples of out- of date stock including dressings, syringes and specimen bottles as well as one example where nutritional supplements were out-of-date. We raised this with staff in order that this could be promptly addressed.