Leeds and York Partnership NHS Foundation Trust

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• 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 previous assessment, we rated this key question requires improvement. At this assessment, the rating remained 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 44 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

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 had been no serious incidents in relation to this service in the 12 months prior to this assessment. There had been 1 incident that required an after-action review and 2 that had required a structured judgment review. This approach was in line with the Patient Safety Incident Response Framework (PSIRF), which sets out the NHS’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents for the purpose of learning and improving patient safety.

All staff we spoke with knew what incidents to report and how to report them. They had access to an electronic system which enabled them to log incidents, for them to be escalated and for them to receive feedback. We looked at a 10 of these records, and they demonstrated staff knew what to report and managers took time to review, process and learn from them.

Staff understood the duty of candour. They were open and transparent and gave patients and families a full explanation if, and when, things went wrong.

Staff received feedback from investigation of incidents, both internal and external to the service. We saw evidence of escalation where incidents needed further investigation and where learning was shared across all 4 wards at regular joint management meetings. Staff met to discuss that feedback, this took place via team meetings, huddles and where necessary at handover meetings, which were held throughout each day.

There was evidence that changes had been made as a result of feedback. We saw an example of an incident that occurred because of a breakdown in communication between staff. As a result of this incident, staff made changes to the way that tasks were noted and shared with those expected to carry them out, this helped to improve communication and minimise the risk of a reoccurrence of this type of incident.

Staff were debriefed and received support after any serious incidents or where they required it. Staff told us managers and more senior staff were on hand to support them when incidents occurred and they said that there were several different opportunities to discuss and receive feedback, such as ad hoc huddles, handovers, supervision and team meetings.

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 service’s referral and admission processes ensured that all essential information about the patient was received to determine if the patient’s needs could safely be met. There was a specific team who managed referrals and they worked effectively with other parts of the organisation to identify options for people. Senior managers, ward managers and medics assessed the suitability of each referral and made the final decision.

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 discussions were taking place and discharge plans were being developed for all patients.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Staff were trained in safeguarding, knew how to make a safeguarding alert, and did that when appropriate. The compliance rate for safeguarding adults and children training was 97% at the time of the assessment.

Staff we spoke with 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. This included working in partnership with other agencies, such as social care teams.

Staff followed safe procedures for children visiting the service. The provider had a policy and procedure in place, which staff had access to.

All wards made use of a blanket restrictions register, which was regularly reviewed and restrictions were appropriate and adjusted or removed, according to current risks on the wards. For example, access to a garden on one of the wards was limited because of the vulnerability of the patient group and the risks posed by unsupervised access to the garden, such as falls but patients were able to access the garden if they were supervised by a member of staff. There was evidence that this restriction was reviewed on a regular basis to make sure it was still necessary and appropriate.

Mental Capacity Act

85% of staff had completed mandatory training in the Mental Capacity Act.

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

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 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. 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.

Staff did not always manage risks to patients and themselves well.

We looked at 11 patient risk assessments and risk management plans during the assessment.

Individual patient observations were a common tool identified to manage risks identified. However, records evidenced that therapeutic observations were not always taking place. We looked at a sample of prescribed therapeutic observation documentation across all 4 wards. We found that records contained gaps where no observations appeared to have taken place, this meant we were not assured that all prescribed observations were being carried out in line with the trust’s policies, potentially putting people at risk of harm. In addition, only 71% of staff had completed therapeutic engagement and observation level 2 training.

There were 369 incidences of restraint across the four wards over the 12 months prior to the inspection, almost all of which were carried out to prevent violence or to support personal care and administer treatment. Staff were appropriately trained to carry out these interventions.

There were 44 episodes of rapid tranquilisation in the 12 months prior to the inspection. Ward teams did not use seclusion or long-term segregation.

Staff involved patients in care planning and risk assessment where it was possible and where it was not possible there was evidence that the views of families and carers had been taken into consideration. Although we did not observe patients, families or carers taking part in multidisciplinary meetings, we heard their views and opinions being fed into the discussions. Patients were offered a copy of their care plan.

Staff communicated with patients so 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. They did this through community meetings and by gathering paper-based feedback from each patient that was admitted to the ward. Staff ensured patients could access advocacy. There were posters and leaflets on the ward.

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.

Staff did regular risk assessments of the care environment, detailed assessments took place periodically and daily checks were also carried out by staff working on the wards.

The layout out of the wards allowed staff to observe all parts of the wards and staff were positioned in areas of the ward where they could observe high risk areas, for example on bedroom corridors where there were more incidents of falls and altercations between patients.

There were some potential ligature anchor points and staff mitigated this risk by increasing the observations for patients that could be a higher risk. However, we were concerned that staff we spoke with did not know where ligature cutters were located, and they did not know what happened in the event of them being used. We spoke to 7 members of staff across all wards and none of them could locate the ligature cutters. We were concerned that in the event of an emergency, staff would not be able to access this equipment in a timely manner. We also asked what staff would do after they had used the ligature cutters, and all staff said they did not know. Good practice guidelines state that ligature cutters should be sent for professional sharpening or have their blades replaced immediately after use to ensure they are ready for future emergencies. We could not be assured this would take place as not all staff were aware of this guidance.

Staff had easy access to alarms and patients had easy access to nurse call systems. Staff and patients said that staff were available to support them when they needed additional support, we also saw staff alarms in use and observed staff responding promptly.

Clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly.

The service had not made sure there were enough qualified, skilled and experienced people, who received effective support, supervision and development. They had not worked together effectively to provide safe care that met people’s individual needs.

Staff had not received or were not up to date with their appropriate mandatory training. Only 64% of staff had completed fire level 3 training. We spoke to the management team about this, and they told us it was a trust wide issue. Only 51% of staff had completed smoking cessation training, only 71% of staff had completed therapeutic engagement and observation level 2 training and only 74% of staff had received training in the Mental Health Act.

Managers had calculated the number and grade of nurses and healthcare assistants required. They did this by carrying our regular staffing establishment reviews, which included the analysis of various data points, quality indicators, the mental health optimal staffing tool (MHOST) and professional judgement. The number of nurses and healthcare assistants matched this number on all shifts.

The ward managers could adjust staffing levels daily to take account of case mix. Ward managers met daily to discuss staffing needs across the wards and to make best use of their resources. Where additional staff were needed, at short notice for example, managers said they had the autonomy and ability to act.

Wards were very rarely short staffed, and if they ever were, a member of the MDT or management team was able to step in to support staff. Staff shortages rarely resulted in staff cancelling escorted leave or ward activities. There were enough staff to carry out physical interventions

There were a small number of vacancies across all the wards, between 7% and 8%. Sickness rates ranged from between 6% and 11% over the 12 months prior to our inspection.

When necessary, managers deployed agency and bank nursing staff to maintain safe staffing levels. Approximately 2% of all shifts were covered by agency staff and approximately 31% of all shifts were covered by bank staff, this represented a slight improvement since the last inspection. Bank staff were mainly used to cover staff sickness and where observation needed to be increased above normal staffing levels. When agency and bank staff were used, those staff received an induction and were familiar with the ward. Bank and agency staff had access to the necessary information they needed to deliver safe care.

At least 1 qualified nurse was always present on the wards. Staffing levels allowed patients to have regular one-to-one time with their named nurse and carry out other social activities.

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

We were not assured that staff assessed and managed the risk of infection or detected and controlled the risk of it spreading effectively.

There was no system in place to ensure that medical equipment such as hoists, walking aids and blood pressure monitoring equipment was cleaned on a regular basis. Stickers indicating equipment had been cleaned were not used consistently and it was therefore not possible for the trust to assure themselves that they were minimising the risk of infection transmission.

All ward areas were clean, had good furnishings and were well-maintained. Cleaning records for the general environment were up to date and demonstrated that the ward areas were cleaned regularly.

Staff adhered to infection control principles, including handwashing and bare below the elbow.

The service had not made sure that medicines and treatments were safe and met people’s needs, capacities and preferences, not all medicines management processes were correctly followed by staff. They involved people in planning, including when changes happened.

Peoples’ medicines were discussed with a pharmacy technician and reconciled on admission to the wards. However, pharmacist support to the ward multidisciplinary teams varied and was limited by capacity within the pharmacy team. On two wards pharmacist support for medicines optimisation was provided at weekly medicines review meetings with the resident doctor. This had not yet been extended to the other wards. An independent prescriber described good support from both doctors and pharmacy.

We saw examples where patients,relativesor advocates were involved in discussions about the risks and benefits of prescribed medicines,for example, when antipsychotics were prescribed forpeoplewith dementia. Some patients and relatives had commented that they had less information about medicines, but the wards were implementing plans to help ensure that they could engage in the patient’s ward round as appropriate. Medicines self-administration was supported andmonitoredby nurses.On one ward we saw that care was taken to ensure a patient prescribed a time sensitive medicine received their doses on time. Where required,theappropriate authorisationfor the administration of mental health medicines was in place. Safeguards were inplacefor the covert administration of medicines. We saw an example of clear joint decision making between the trust doctors and another medical speciality when a patient was physically unwell. Care plans and risk assessments captured information about people’s needs relating to medicines.

However, we also saw one example where medicines were not prepared individually for administration, in line with current guidance. We raised this concern with managers and immediate action was taken to address this. Additionally, on three occasions physical health observations had not been recorded for the duration described in trust policy following administration of an injection prescribed for one patient, this was an issue that had been identified at our previous inspection of the service. Similarly, we also saw a small number of gaps in blood sugar monitoring records for two patients.

Medicines for leave away from the ward were supplied to patients in a timely way. The trust sought feedback from patients, with one patient commenting that they had enough support and information about their leave medicines stating that they “received a printout and all tablets are easy to manage”. A recent trust audit (reported August 2025) looking at the quality of discharge letters sent to GP’s showed improvement in several areas against the previous 2020 audit. Any areas identified for improvement including delays in providing the medicines information to the GP, were shared for learning. An action plan was in place with plans for re-audit later in 2026.

Medicinesincluding controlled drugs were safely stored.Regular audits were carried out, and we saw that a recent controlled drugs error was appropriately escalated for review and learning. This area of work had been improved since the last time we inspected this service.