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 previous assessment we rated this key question good. At this assessment, the rating has changed to requires improvement. This meant the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred 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.

Leaders had 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 and this was evident in the feedback that we received from patients. Staff were committed to the service and spoke passionately about the patients they cared for.Staff we spoke with were happy and motivated, and felt able to raise concerns. 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.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They 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 we spoke with knew who the managers and senior leaders were within the service and the wider trust. Staff felt listened to and supported by their managers and senior managers to undertake their roles. We heard how senior leaders attended the wards to engage with staff and patients. However, data provided to us by the trust evidenced one visit from the Chief Executive and none from any other executives in the 12 months prior to inspection. Staff said 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 and team meetings. 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. 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.

Leaders 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 the 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.

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 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 on flexible working arrangements.

The evidence from other key questions demonstrates service had not always displayed good governance or suitable oversight of systems and processes. The service had also failed to act on a previous breach of regulation.

We found that managers had not taken appropriate steps to ensure staff were adhering to infection prevention and control standards as there was no process in place to ensure medical equipment was clean. Managers had also not identified or taken action to address gaps in individual patient observation records, therefore they could not be assured that they were taking place. Managers had also failed to ensure that staff had carried out all their mandatory training to enable them to keep people safe.

At the previous inspection of this service, we identified a breach of Regulation 12 in relation to the failure to carry out physical observations following the use of restrictive interventions. The trust had failed to take the necessary action to improve this practice.

The trust must ensure that systems are in place to ensure that staff carry out physical observations following the use of restrictive interventions that are in line with national guidance. - Regulation 12.

Managers had access to information to support them with their role. This included information on the performance of the service, staffing and patient care. Managers received and reviewed reports concerning different elements of the service. These included medicines management audits, and care plan and risk assessment audits. However, despite these systems, we still identified some areas where processes were not operating effectively.

Managers maintained and had access to the risk register. Staff at ward level could escalate concerns when required. Current risks included ligature anchor points and other physical environmental risks, these risks were being suitably mitigated and action taken to reduce them.

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 had access to the equipment and information technology needed to do their work. Although some staff said whilst the electronic patient record and internet access was slow, they were able to use it effectively. There was also a range of physical equipment needed to support and monitor people with mobility issues and physical impairment.

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

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 the Care Quality Commission.

The service understood their duty to collaborate and work in partnership, so their services work seamlessly for people. They shared information and learning with partners and collaborated for improvement.

Managers described good working relationships with a range of external stakeholders. These included the neighbouring trusts, the local authority, social care providers and community support teams. 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 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 patient’s care.

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.

The service focussed on continuous learning, innovation and improvement across the organisation and the 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.

The service was involved in several clinical improvement programmes, for example a project which aimed at improving the quality of inpatient GP discharge letters. They had also carried out a bed reduction programme over the last few years which saw the wards reduce the number of beds to enable them to provide more focussed care.

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 4 was assigned the Quality Improvement workstream as part of the Culture of Care initiative when the pilot programme launched in 2024. This programme has seen developments and changes in staffing structures, handovers, carer and family involvement and the way in which staff supervision is carried out, including how staff wellbeing is supported.

Staff had developed a video to guide staff on how to carry out swarm huddles more effectively, feedback about this piece of work had been very positive. A swarm huddle is a rapid, blame-free team meeting held within 24–48 hours of a patient safety incident.

The service had also trained many staff to be able to carry out dementia care mapping, and more staff were due to undertake this training. This would allow the wards to more effectively assess the environment, interactions and culture to ensure that they can best meet the needs of people being treated on the wards.

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, to ensure AI could be used reliably and effectively.