Leeds and York Partnership NHS Foundation Trust

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• 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 inspection we rated this key question requires improvement. At this inspection the rating has changed to inadequate.

Inadequate: This meant there were widespread and significant shortfalls in service leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

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 scored the service as 3. The evidence showed a good standard. The service had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Quality Statement Score: 2. We scored the service as 2. The evidence showed some shortfalls. Not all leaders understood the context in which The service delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

Although we found that leaders had the skills, knowledge and experience to perform their roles, we found a number of shortfalls within the service during our inspection, and data analysis of the service. This included concerns around areas such as training, care plan audits, fire safety and the maintenance of the estate. The presence of these unaddressed issues, meant that governance processes were not robust enough to ensure the service was running safely.

The staff and patients we spoke with did not raise any concerns about ward managers and senior leaders.

Leaders were visible in the service we visited and approachable for patients and staff. Ward managers were based on the wards and staff told us that they found their local leaders to be accessible. There were leadership training opportunities for staff, such as courses in managing people, managing attendance and leading a team, as well as opportunities to complete the Mary Seacole NHS Leadership Academy programme.

Quality Statement Score: 3. We scored the service as 3. The evidence showed a good standard. The service fostered a positive culture where people felt they could speak up and their voice would be heard.

The trust had a Freedom to Speak Up Guardian and ambassadors within services. Their contact information was displayed on posters throughout the wards. Staff described that they could raise any concerns that they might have without any fear of retribution. Managers were confident that staff would speak up if they had any concerns.

Patients and carers had opportunities to give feedback on the service they received in a manner that reflected their individual needs.

Managers and staff had access to the feedback from patients, carers and staff and used it to make improvements. Examples of changes made following patient feedback included, purchasing of board games, and a pool car to facilitate leave, and organising day trips to Scarborough and bowling.

Patients and carers were involved in decision-making about changes to the service. For example, on Newsam Ward 5, we saw displays about the new rehabilitation ward that was being built, with feedback sought from patients on decoration and furniture. However, the move to this ward was delayed.

Patients and staff could meet with members of the provider’s senior leadership team and governors to give feedback. The matron for the service completed regular walk around visits on the wards and patients were able to approach them if they had any questions or concerns. Patients were also able to raise any questions or concerns during the ward community meetings that took place each week, attended by the ward managers.

The most recent staff survey results showed a 40% uptake in staff completing the survey for the rehabilitation service overall. The survey saw a downward trend in several areas including, staff wellbeing, burnout, raising concerns, appraisals, work life balance and wellbeing and work pressure. The year on year data from 2024 to 2025 showed a downward trend in 16 out of 29 categories although some were negligible in the difference. The ones noted were either highlighted as an amber or red showing a more noticeable decline in scores.

Quality Statement Score: 3. We scored the service as 3. The evidence showed a good standard. The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who work for them.

There were equality and diversity champions within the service .Asket House and Asket Croft had also recently engaged in a project around social justice, which was led by the consultant psychologist, and focused on anti-racist practice. This allowed a space for reflection on social inequalities patients in mental health services face and how this can impact their wellbeing. This project also aligned with national policies in this area such as Patient and Carer Race Equality Framework (PCREF) and the culture of care standards for inpatient wards under standard 5 - Equality.

Staff were able to apply to work flexibly including flexible working agreements to account for personal circumstances such as caring responsibilities and health issues.

Managers put reasonable adjustments in place for staff members to help them carry out their role.

Staff received equality and diversity training with a compliance rate of 100% across the service.

Quality Statement Score:1. We scored the service as 1. The evidence showed significant shortfalls. The service did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Not all of the information the trust provided to us was accurate. We requested information from the trust around complaints for the 12 months preceding our on-site inspection. In the data returned, no complaints were noted. However, we noted when reviewing team and clinical governance meeting minutes that minutes from the complex psychosis pathway clinical governance meeting in February 2026 stated that a complaint was received for Newsam Ward 5 in December 2025. This was not noted in the complaints data we were provided. No further information was noted in the meeting minutes, so we are unable to further explore the details or nature of this complaint. Similarly, Asket House noted a complaint in each of their January and February 2026 meeting minutes, and these were not included in the complaints data we were provided. It was also noted that complaints were not a standing agenda item on the Newsam Ward 5 team meeting agenda. It was therefore unclear if leaders were aware of these complaints or whether appropriate action had been taken. Additionally, it demonstrated a lack of effectiveness with regards to current reporting structures.

Staff undertook or participated in local clinical audits. However, we found that these audits were not always sufficient to provide assurance, or to identify concerns.

We found the environment on Newsam Ward 5 was in a poor condition. The ward was not clean and the governance systems in place were ineffective in remedying these issues in a timely manner. Although a monthly audit was carried out, this often identified the same issues, with no actions being evident. In several cases, environmental works were not documented to be incomplete because patients had not allowed access to their bedrooms. There was no clear process for revisiting to ensure the work was completed after discussions with the patient.

We found that there were ongoing estates issues impacting on patient care, including a bedroom with no running water which was reported several times on the estates log, dating as far back as November 2025. Other issues were also on the estates log several times, included lights not working, constantly running water in toilets and marks from leaks on ceilings. The estates logs provided failed to show a clear audit trail of the progress of works to be completed, nor was there any prioritisation of actions or apparent consideration of impact to patients.

Records evidenced there would often be a back and forth on the estates log between estates staff and ward staff about whose role it was to carry out certain areas of work. An example of this was when bodily fluids were present in a patient’s bedroom sink. This had been added to the estates log for cleaning, but identified the ward staff would need to remove the bodily fluids first. The estates log noted they had visited to clean the sink, but staff had not removed the bodily fluids at that time. There was no note to confirm next actions, when they would expect the job to be completed by or who would take the lead on this. Therefore, we were not assured necessary actions to improve the environment were taken in a timely manner, or were adequately overseen to ensure completion.

We found that the care records audit for Newsam Ward 5, had not identified that there was no reliable system to review when care plans were updated. Although the electronic records system did allow for this feature, we found it was not common practice for staff to utilise this. In addition, the clinic room audits had not identified out of date equipment in the clinic rooms and on one occasion in the emergency bag. We found these items were not included in the clinic room audit checks and therefore the issue had not been identified as something that required action. We were not assured that the processes in place were effective in identifying concerns in order to ensure the safety of patients.

We were also concerned about a lack of governance and effective oversight in relation to patient safeguarding procedures. We noted that in 7 of the 8 concerns shared with us by the trust, there was no evidence that the advice given by the specialist safeguarding team, to make a referral to the Local Authority safeguarding team, had been completed. There was no system in place at the time of inspection to ensure recommendations were acted upon. This lack of oversight in safeguarding processes placed patients at significant risk, as potential abuse or harm may have gone unaddressed.

Staff understood the arrangements for working with other teams, both within the provider and external, to meet the needs of the patients. However, as mentioned above, we were not assured that advice given by the specialist safeguarding team to make referrals to the Local Authority safeguarding team had been completed, meaning the local authority may not have a robust overview of safeguarding concerns within the trust.

Management of risk, in relation to fire, was ineffective. The training provider contracted by the trust to provide fire safety training had withdrawn their provision in December 2025. At the time of our on-site inspection, there was still no plan in place to ensure ward staff were trained to the correct level. Training compliance for level 3 fire safety was low across all 3 wards; Asket House 65%, Asket Croft 60% and Newsam Ward 5 76%. 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. We requested the fire risk assessments as part of our data request following the on site inspection, we were provided with these, but no associated action plan to tell us how any concerns were managed and when they were expected to be rectified. We later received them as part of the data request for our well led inspection of the provider, after querying why there were no actions plans with the risk assessments. This did show that actions were largely completed Lastly, although fire evacuation plans were present for all 3 wards, each ward utilised a different format, and contained different levels of detail of what action staff should take in the event of a fire. Despite Asket Croft and Asket House being co-located, their fire evacuation plans were not of the same format, some were much more detailed than others and it was unclear why there was not a uniform approach to fire evacuation in terms of level of detail included to support staff in the event of an evacuation.

The culmination of these concerns demonstrated a significant lack of effective oversight and management of fire related risks to ensure patient and staff safety in the event of a fire. The failure to maintain up-to-date fire safety processes placed patients at real risk of harm in the event of a fire. The absence of training, updated fire risk assessments and a uniform approach to fire evacuation plans, meant staff would be ill-prepared if exposed to a potentially life-threatening situation.

The service had a governance structure which enabled communication from ward level to senior management within the service. There was a clear framework of what must be discussed at a ward, team or directorate level in team meetings to ensure that essential information, such as learning from incidents and complaints, was shared and discussed. We reviewed team and governance meeting minutes from the 3 months prior to our inspection and found that these all had a clear agenda, actions log and pathways for escalating information up and down the service.

Staff had implemented recommendations from reviews of deaths, and incidents and we were able to see where incidents were discussed each month in team meetings, including themes and trends in the number of incidents and types of incidents. Smoking incidents appeared in all of the ward team meeting minutes with an increase in patients having access to ignition sources on wards.

Staff had access to the risk register at ward and directorate level. The risk register only contained one risk for each ward and this was in relation to risks around ligatures in the environment. However, we did not see the issues we found on inspection reflected on the risk register, such as lack of adherence to mandatory training, fire risks, audits of care plans and the ongoing maintenance of the environment added to the risk register Staff concerns did not match the level of concerns we found within the service. We did not see any barriers to staff escalating concerns when required.

The service had plans for emergencies such as adverse weather or a flu outbreak. However, this was not the same for fire risk, as staff training compliance was low and therefore we were not assured staff on duty would be clear on how to keep patients safe if a fire broke out in the service.

Where cost improvements were taking place, they did not compromise patient care.

Staff had access to the equipment and information technology needed to do their work. The information technology infrastructure, including the telephone system, generally worked well and helped to improve the quality of care.

Information governance systems included confidentiality of patient records.

Team managers had access to information to support them with their management role. This included information on the performance of the service, staffing and patient care.

Information was in an accessible format, and was timely, accurate and identified areas for improvement.

Quality Statement Score: 3. We scored the service as 3. The evidence showed a good standard. The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They shared information and learning with partners and collaborated for improvement.

Directorate leaders engaged with external stakeholders – such as commissioners and Healthwatch. The service also engaged well with the voluntary sector to ensure patients on the rehabilitation pathway had access to local community projects and groups.

Patients and staff could meet with members of the provider’s senior leadership team and commissioners to give feedback.

Quality Statement Score: 3. We scored the service as 3. The evidence showed a good standard. The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

Staff were given the time, support and opportunities for improvements and innovation and this led to changes. Examples of this included the recent purchase of a ward pool car for Newsam Ward 5, to enable patients to get out more into the community.

Staff had opportunities to participate in research. The trust had an active research department, and they often visited the wards to attend meetings, where they explained to the staff about research opportunities that may suit their patient group. We observed a meeting on the day of our on-site inspection where the research department attended to explain about a new opportunity relating to the experience of black males in mental health settings. They asked staff to speak with patients who may be interested in engaging in this research.

Innovations were taking place in the service. Asket House and Asket Croft had worked together with a third sector organisation to complete a baseline review of their patient involvement and coproduction work. This then led on to the development of a coproduction strategy and action plan which the teams had been working on through 2025 and early 2026. Some examples of the work completed included; development of a service user reference group in September 2025, that meeton a monthly basis. Development of coproduction training, which was coproduced with patients. Development of interview skills training in collaboration with the recovery college, to help develop the skills of people with lived experience on interview panels. Development of “Champions of Change” meetings for patients to come together atAsketHouse andAsketCroft.

Staff used quality improvement (QI) methods and knew how to apply them. The team had completed a QI project around a reducing number of patients attending their multi-disciplinary team meetings. The project looked at how to develop an achievable and sustainable process whereby patients' views were explored, and the MDT process was adjusted to meet their needs.​

Staff participated in national audits relevant to the service and learned from them. The service completed the quality indicator for rehabilitative care (QUIRC)which assessed the provision of care across seven domains considered to be important for recovery.This measure was completed on an annual basis toprovidean ability to measure and improve practice in the rehabilitation services against the national benchmark.Latest QUIRC review showed that Asket Croft scored above the national average for measures such as self-management, autonomy, social interface and human rights.

Wards participated in accreditation schemes relevant to the service and learned from them. Asket Croft and Asket House were accredited with the Royal College of Psychiatrists Quality Network for Mental Health Rehabilitation Services until May 2027.