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
• Environmental sustainability – sustainable development

We have not awarded this service a score for Well-led.

Find out about when we will not publish a key question score and what we look at when we assess Well-led.

The trust had a clear, shared vision and strategy focused on transparency, equity, human rights, diversity, inclusion, and meeting the needs of its local communities. However, some key patient safety issues had not been addressed promptly, suggesting action plans created to drive forward strategy aims were not always effective. Additionally, despite the clear vision and strategy, staff survey responses indicated that the values set out in the strategy were not always reflected in day-to-day practice and culture.

In assessing this Quality Statement, we considered feedback from leaders, staff, people using the services and local system partners, as well as reviewing trust processes and survey results and the trust’s current strategy (2025-2030) at the time of the inspection, “Improving the health and lives of the communities we serve” as well as their values and vision. The trust provided examples of how partners had been engaged in the development of the trust’s strategy. Partners, including those with established relationships with the trust, gave positive feedback that confirmed the assertions that they had been involved in the development of the trust’s strategy. Partners were satisfied that the trust’s strategic objectives were aligned to the objectives and priorities within the local system.

The overarching strategy was underpinned by the following five core strategic plans, which the trust described as “providing the finer detail on what we’re doing, how we’re doing it, and by when”;

• Care services (2023-2028) – making care services fit for the future and sustainable
• Estates (2025-2030) – to create a modern, sustainable, and fit-for-purpose estate
• People (2024-2027) – valuing people to improve care and health outcomes
• Quality (2023-2028) – to create the conditions in all areas of the organisation for quality to be experienced
• Green Plan (2025-2030) – leading the way to Net Zero, commitment to sustainability and climate resilience

Strategic plans were supported by yearly organisational priority goals that set out the tasks, action and activities to be the focus of that year. For the financial year 2025/2026 these were broken down into three categories of “how we are operating effectively”, “how we are improving the quality of our care services” and “how we are running our organisation effectively”’. Some examples of priorities were the delivery of an Inpatient Quality Transformation and Improving Patient Flow Programme and delivery of a workforce efficiency programme. However, despite the focus on these goals for the past 12 months, and close monitoring by the trust, we saw little improvement in areas such as patient flow, with out of area placements remaining high with minimal improvement realised.

The trust’s vision was “to lead the way in mental health, learning disability and neurodiversity care so the communities we serve can live healthy and fulfilling lives, our people can achieve their personal and professional goals, and everyone can live their lives free from stigma and discrimination”. With values of:

• We have integrity; we treat everyone with respect and dignity, honour our commitments and do our best for our service users and colleagues
• We keep it simple; we make it easy for the communities we serve and the people who work here to achieve their goals
• We are caring; we always show empathy and support those in need

The values were well-established across the trust.

The trust’s ability to measure success against its strategic plans and objectives were outlined in their board assurance framework (BAF). Whilst the trust BAF was concise and provided clear oversight of key risks, there was a notable difference between this, and the trust risk register (containing a combination of operational/local risks and directorate/service line risks) sitting underneath it. This combined risk register contained a high number of risks; 128 risks as of March 2026, 66 of which had ongoing actions required to mitigate them. This made it unclear which were key to reducing those strategic risks on the BAF which implied a weakened relationship between frontline operational controls and strategic assurance, with risks being known and reviewed regularly, but not always clearly reduced in a timely manner. The trust would benefit from strengthening the position between BAF risks and specific outcomes detailed within the combined risk registers to provide greater assurance that risk mitigation actions were effectively leading to clear improvements in safety and quality of service provision and delivery of trust strategy.

A structured pharmacy recovery plan, ‘Getting to Good’, had been established to support service delivery and improvement, following a period where pharmacy services were in business continuity (June 2022 to December 2024). Progress was monitored through six-weekly recovery oversight meetings led by the medical director. Although current focus remained largely on frontline delivery, there was a growing emphasis on more strategic planning for the future. The chief pharmacist now attended the extended executive management team meetings, enabling monthly executive engagement, helping to raise the profile of pharmacy and medicines optimisation in strategic decision making. However, there was less visibility of how medicines optimisation supported delivery of the trust quality strategic plan and care service priorities. There was no long-term medicines optimisation strategy or pharmacy workforce plan.

Culture
Executive leaders demonstrated their commitment to compassionate and inclusive leadership and were positive about the trust’s culture and promoting staff and patient voice at all levels. However, data and staff narrative highlighted the need for leaders to focus on identifying the work required to make necessary improvements in culture.

The NHS Staff Survey provides insights into staff engagement, morale, and workplace experience. In 2025, LYPFT had 1,504 completed questionnaires with a response rate of 45%, which was lower than the national rate of 52% for Mental Health and Learning Disability and Mental Health, Learning Disability and Community Trusts. LYPFT’s response rate had been below the national rate each year since 2020, despite evident work by leaders and the staff engagement team to encourage participation.

The 2025 survey provided evidence that staff engagement had steadily declined since 2024. The trust scores for the element of ‘we are safe and healthy’ and the theme of 'morale' were significantly lower when compared to 2024. Key sub-themes such as motivation, involvement and advocacy all showed a downward trend since 2024, with motivation steadily declining since 2020 and coming in below the national rate.

However, the trust scores for sub-themes within the element of ‘we each have a voice that counts’ were largely above national rates. For example, the trust scored above the national rate for ‘I feel safe to speak up about anything that concerns me in this organisation’ and ‘I am involved in deciding on changes introduced that affect my work’.

From our assessment service group inspections, we found staff understood and lived the trust’s vision and values and these had been communicated clearly by senior leaders. Staff felt well supported by colleagues and managers and were generally proud of working for the organisation. There was evidence of a positive safety culture, with staff feeling able to raise safety concerns and challenge unsafe practice. The trust’s People Plan (2024-2027) clearly outlined the aim to support staff to be the best they can be at work, including wellbeing support and creating and maintaining a psychologically safe culture. The trust also had an ongoing objective to embed cultural awareness and training across the trust.

Service user and carers stories were a key feature at trust board meetings. Trust executives told us that they found the stories powerful and encouraged presenters to share their perspectives on areas for development of services. Board papers reviewed evidenced clear engagement from trust executives, with actions taken away based on the stories shared.

Stakeholder feedback with regards to culture was largely positive, although one partner reflected that the trust could be “insular in its’ thinking” with trust colleagues telling them internal communications were lacking with regards partnership working, and feedback about crisis support and community mental health services being that care was not always compassionate or progressive.

The trust placed consideration of health inequalities at the heart of its ways of working. Governance processes ensured consideration of differences in access and outcomes which were used to improve outcomes for all. The trust had partnered with Public Health, the local community and voluntary sector organisations to create ‘Synergi-Leeds’; a citywide approach to tackling ethnic inequalities in mental health. The partnership was named ‘Mental Health Innovation of the Year’ at the Health Services Journey (HSJ) awards in November 2023 and focused on tackling the issue of overrepresentation of people from Black, Asian and minority ethnic communities admitted to crisis mental health services or detained under the Mental Health Act. The trust had also, in the 18 months prior to our inspection, introduced a Head of Health Equity role, supported by a small team, who described some of their work with local populations around health equity to benefit from the expertise of those with strong community links and experts across the region.

The trust had processes to identify and address behaviours that were inconsistent with the values of the NHS. However, the trust’s grievance and disciplinary policies were not within their review dates at the time of our inspection. The disciplinary policy was six months past its review date, and the grievance policy by 2 months at the time of our inspection.

We reviewed 5 examples of grievance, and 5 of disciplinary and all had been completed in line with the trust’s processes. Processes to ensure staff remained fit and proper for their roles was effective and ensured staff remained qualified and suitable for the role they had.

The trust had inclusive leaders who understand the context in which they deliver care, treatment and support and embody the culture and values of their workforce and organisation. They had the skills, knowledge, experience and credibility to lead effectively. 

In assessing this Quality Statement, we considered feedback from leaders, staff, people using the services and local system partners, as well as reviewing trust processes and survey results.

The Chief Executive Officer joined Leeds and York Partnership NHS Foundation Trust in September 2016. As of June 2025, they were also appointed the CEO for Leeds Community Healthcare NHS Trust and were working with both boards to look at the future opportunities for better integration of services. The CEO demonstrated a clear commitment to lead the trust through significant change and was conscious of the challenges they faced in this. Our observations and discussions demonstrated a passionate leader who was well supported by both internal and external partners.

The trust Chair had been in post since January 2023. They bought over 30 years of experience in Local Government, leading services across housing, social care, culture and community development. As a previous non-executive director, they also brought operational and strategic insight to the board. The Chair was passionate about strengthening the culture of the organisation and acknowledged the staff survey highlighting there was work to do.

The trust’s board comprised of 6 executive directors including the CEO and 7 non-executive directors including the Chair, representing a broad range of experience and professional backgrounds. The executive team held a range of individual portfolios covering areas including quality, effectiveness, estates, risk management, finance, procurement and organisational development. However, we identified that whilst some of the non-executive directors demonstrated digital expertise, this was an identified gap within the executive team.

There was a board development plan in place with several internal strategic development sessions planned to take place between February 2025 and February 2026. Sessions included cyber training, finance and estates, and culture. The board had not undertaken any externally facilitated board development work since October 2024.

The executive leadership team worked in a triumvirate model with the Executive Medical Director, Executive Director of Nursing and Professions and Chief Operating Officer (COO). All 3 leaders valued the importance of working together whilst each taking the lead in particular areas. For example, the medical director took the lead on improvement and innovation, the director of nursing and professions leading on quality, regulation and standards, and the COO leading on implementation and performance. 

We observed trust board meetings, attended several governance meetings and reviewed minutes. These included quality committee, people committee, and finance, performance and digital committee. In all meetings we saw leaders acting with integrity, effectiveness, credibility and kindness. The trust actively supported diverse communication needs and ensured meetings were accessible. There was a focus on workforce risks and performance, access to services, staff wellbeing, and oversight of exceptional incidents.

Leaders told us they undertook regular visits to frontline services. These visits were aimed at improving leadership visibility and ensuring leaders were able to triangulate the information received through the trust’s governance systems, particularly in relation to staff experience. Leadership visits to services were planned across the year to be undertaken by a member of the executive team along with the trust chair or a non-executive director. We reviewed the schedule between February 2025 and February 2026 and found 7 visits were scheduled, with only 5 of these taking place. The trust CEO explained no minimum number of visits was set but that there should be coverage across all services. With only 7 visits scheduled and 5 carried out, this evident ambition of coverage did not take place in the 12-month period we reviewed. The CEO themselves scheduled 13 visits within a similar 12-month period, summaries of which were detailed in public board papers and internal CEO reports.

Of the 5 service visit reports received, we noted records highlighted strong teamwork and commitment to compassionate care across teams. However, significant challenges remained, largely relating to environments and estates, but also citing lack of closed-circuit television (CCTV) and staffing concerns including recruitment. Some teams also reported high rates of incidents and the impact of this on staff. Actions were not clearly documented following all visits. The trust would benefit from ensuring service visit coverage across all services, as indicated should be in place, to ensure a more rounded view of services and care provision.

Within pharmacy there was a strong focus on management team development strengthening the skills, behaviours and knowledge that support leaders to drive the pharmacy recovery programme forward. Training requirements for all pharmacy roles had been reviewed and a further training needs analysis was underway to identify core but non-mandatory training requirements. Pharmacy staff were positive about the culture within their local teams telling us about a “good culture” and feeling “respected”. They felt managers were approachable and aware of pressures the teams faced. There was recognition of efforts by the pharmacy leadership team to become more visible.

Staff network representatives described senior leaders as supportive, particularly at the executive level. Leaders were recognised for encouraging staff networks and responding promptly to queries or requests for support. However, concerns were raised about the executive sponsors of some of the networks, with some networks highlighting they needed sponsors who were more visible and active in the role.

Staff-side (union) representatives described positive working relationships with leaders; highlighting open communication, and confidence that action would be taken, giving an example of working together to reduce spend on agency staff. However, they also raised concerns about the leadership focus on staff sickness rather than considering the wellbeing of those who remain in work, variation in attitudes towards flexible working across the trust, and the lack of staff-side involvement in ongoing discussion around the trust’s estate, despite the significant impact this has on the workforce.

Most partners told us leaders were visible within the local system but feedback about their experiences were mixed. One partner described the board and senior leaders as “strong”, “credible”, “visible”, and “authentic”, whilst another commented that the trust did not always seem to work in the best interests of its’ people and service users and could be too focused on internal sustainability rather than effective partnership working. Partners shared examples of positive partnership working, highlighting visionary leadership and joint achievements in areas such as the complex emotional needs service and psychological therapies. However, one partner also told us that whilst more junior colleagues embodied positive values, they observed that inefficiencies in leadership meant these were not always evident in observed day-to-day practice.

There was evidence that leaders were visible across the wider local system, regularly engaging at strategic and operational levels through multi-agency meetings, management forums, and partnership boards. Some examples were, the trust working alongside Leeds City Council on ‘Ambitions’; a programme to tackle poverty, reduce health inequality and improve quality of life, and the trust Chief Financial Officer chairing the Leeds City Council ‘One Public Estate (OPE)’ board, delivering integrated health and social care hubs across the city.

Fit and proper persons checks were in place for all directors in line with the requirements of the regulation. We reviewed 5 files which all evidenced the trust had completed appropriate checks of directors’ suitability for their roles. All directors had received an annual appraisal within the previous year.

The evidence that we reviewed demonstrated an open culture in which staff generally felt able to raise concerns, report incidents and suggest improvements. Staff were mostly confident that their feedback, suggestions and concerns would be welcomed and lead to improvements in the trust. However, data indicated improvement was required in relation to staff reporting incidents of bullying, harassment abuse and/or discrimination.

In assessing this Quality Statement, we considered feedback from leaders, staff, people using the services and local system partners, as well as reviewing trust processes and survey results.

Leaders’ role-modelled good speaking up behaviours, they listened to staff feedback and concerns, and they demonstrated candour and empathy when things went wrong.

Two freedom to speak up reports were submitted to the board in the 12 months prior to the inspection, in May 2025 and November 2025. In the period 16 November 2024 to 30 April 2025, there were 32 new concerns raised through the FSUG. This represented an increase from 29 concerns in the same period the previous year. In the period 1 May 2025 to 31 October 2025 there were 39 new concerns that were raised through the FSUG. This represented an increase from 27 concerns in the same period the previous year. The most common themes across both periods were unfair workplace practice or process concerns, bullying/inappropriate behaviour, patient safety concerns, and discrimination allegations relating to race and/or gender. Concerns were raised across a range of areas and services. The trust reported to the National Guardian Office on a quarterly basis and national data showed that between April 2024 and March 2025, staff raised 59 concerns with their FSUGs. When comparing LYPFT to 5 other NHS trusts in the North East, North West and Yorkshire of a similar size (each with less than 5,000 employees), LYPFT was around the median in terms of cases reported. For context, LYPFT reported between 13 and 18 cases per quarter. The lowest per quarter for a comparable trust was 2 and the highest 40.

Further insight regarding the trust’s speak up culture was derived from staff surveys. Results from the trust’s most recent staff survey showed a decline in staff feeling able to speak up about anything concerning them (70.38% in 2024 to 66.03% in 2025) as well as in staff feeling confident the trust would address their concerns (56.92% in 2024 to 54.14% in 2025). The results were above the national average scores, but response rate to the staff survey was low at 45% and therefore may not be considered to represent the views of the majority.

From 2024 to 2025 staff survey results also evidenced an increase in staff from all other ethnic groups (non-white) reporting harassment, bullying or abuse from other staff of just under 3%, whilst white staff reported a decrease of just under 1%. There was a small decrease in staff from all other ethnic groups reporting discrimination at work from a manager, team leader or colleague (13.25% in 2024 to 12.92% in 2025) which was also just above the national average of 12.69%.

Trust data from February 2025 to February 2026 evidenced that 83 incidents of racial abuse towards staff were reported in this period. Of these, 73 incidents involved racial abuse from patients towards staff, and 10 incidents involved racial abuse from ‘other’ sources, which the trust told us may include staff, family members, or visitors. In addition, 9 grievances were submitted by staff within the same reporting period citing bullying, discrimination, or racial abuse as the nature of the grievance.

The was one FSUG in the trust. The trust had recognised the amount of protected time required to undertake the role successfully and had recently increased the FSUG role to full-time. There were also 5 freedom to speak ambassadors within the trust whose role it was to offer peer-to-peer support, designed to champion a positive speaking-up culture. The ambassadors were able to signpost peers as well as escalate cases to the FSUG where necessary. The trust had recognised the importance of these roles and was in the process at the time of the inspection of appointing an additional 8 ambassadors with the idea of focusing them in areas where contacts were currently low.

The FSUG described feeling fully involved in the board, with director support from the CEO as well as non-executive director sponsorship. They felt valued and motivated by the role and felt the role importance was understood and promoted by senior leaders. The FSUG held regular meetings with service leads to resolve and check on progress of actions and reported to board twice per year. Reports were simplified following feedback and a recent audit provided significant assurance. The FSUG reflected that ‘Speak Up’, ‘Listen Up’, and ‘Follow Up’ training modules were not currently mandated at the trust, and following review of completion rates alongside board reflections and work already done to improve training uptake, had made the decision to apply for training (level 1) to be compulsory and were awaiting a decision on this. The FSUG was also considering how they could share successes more widely without compromising confidentiality, in order for staff to see the benefit of utilising freedom to speak up if they so required it.

We spoke with a range of staff members during our ASG inspections. Freedom to speak up was well understood and promoted within services and leaders encouraged staff to speak up and raise concerns. Staff spoken with felt confident and comfortable to raise concerns and could give examples of where this had happened and led to changes. We offered staff the opportunity to feedback directly to CQC during the well-led assessment via an online experience form but did not receive any responses.

The trust demonstrated a willingness to learn and improve with regards workforce equality, diversity and inclusion and were in the early stages of plans for positive change. However, we did not evidence of embedded change or sustained improvement as this stage. Additionally, whilst we saw increases in representation within the workforce in general, there was work to be done to address representation on the board, as well as declining workforce diversity metrics showed that some staff continued to experience disadvantages while working at the trust.

As part of the NHS Staff Survey, the workforce race equality standard (WRES) highlights potential differences between the experiences of white staff and staff from ethnic minority groups. Much like the WRES, the workforce disability equality standard (WDES) allows NHS trusts to compare the experiences of staff with a disability, a long-term condition and other types of illnesses, with those of non-disabled staff.

At LYPFT, data from 2025 evidenced people from ethnically diverse backgrounds made up 25% of the workforce (up by 2% since 2024). This was above the current 2021 Census figures for Leeds which identified that 21% of the population were from an ethnically diverse background. However, board representation was not as strong, with the percentage difference between the organisation’s board voting membership and its overall workforce (BME representation) increasing from -7.7% to -9.2% between 2024 and 2025. The trust had identified that “the recruitment of a more diverse board is something that will need to be considered as board members step down”.

At LYPFT, data from 2025 evidenced that 12% of the workforce (excluding bank) had a disability or long-term health condition. This was an increase of 2.5% when compared to 2024 and higher than the March 2024 figure which showed 5.7% of the workforce across NHS trusts nationally declared a disability through the Electronic Staff Record (ESR).

In the WRES, 5 of the 9 metric areas got worse for staff from ethnically diverse backgrounds from 2023/2024 to 2024/2025. The areas showing an unfavourable change were:

• The likelihood of white staff being appointed following shortlisting increased from 2.00 to 2.90
• The likelihood of ethnically diverse staff entering the formal disciplinary process increased from a likelihood of 1.93 to 2.37
• The percentage difference between the organisation’s board voting membership and its overall workforce (BME representation) showed an under-representation
• The percentage of staff experiencing harassment, bullying or abuse from staff in last 12 months increased (from 17.1% to 17.8%)
• The percentage of staff who in the last 12 months personally experienced discrimination from their manager/team leader or colleagues increased (from 10.2% to 13.25%)

Similarly, in the WDES, 7 of the 10 metric areas got worse for staff with a disability or long-term health condition from 2023/2024 to 2024/2025. The areas showing an unfavourable change were:

• An increase in the number of staff with disabilities/LTHCs experiencing harassment, bullying or abuse from patients, service users, and the public (from 25.74% to 26.73%)
• An increase in the percentage of staff with disabilities/LTHCs staff experiencing harassment, bullying or abuse from colleagues (from 17.16% to 17.64%)
• A decrease in the percentage of staff who believe that the trust provides equal opportunities for career progression or promotion (from 59.3% to 53.2%)
• An increase in the percentage of staff who say they have felt pressure from their manager to come to work, despite not feeling well enough to perform their duties (from 14.85% to 15.9%)
• A decrease in the percentage of staff satisfied with the extent to which the organisation values their work (from 47.4% to 45.65%)
• A decrease in the percentage of staff saying their employer has made reasonable adjustments to enable them to carry out their work (from 86.54% to 80.9%)
• The staff engagement score decreased (from 6.90% to 6.69%).

The trust’s annual WRES and WDES report was presented to the board in September 2025. It acknowledged the work the trust had undertaken since the previous years’ WRES and WDES report against issues raised, whilst highlighting significant areas for improvement still required if the trust is to improve the experience of its’ ethnically diverse workforce and staff with disabilities and/or long-term health conditions. Some of the work undertaken since the 2023/2024 report included the appointment of a substantive head of equality, diversity and inclusion, recruitment of additional freedom to speak up ambassadors, roll-out of values-based recruitment across key services, and piloting of a cultural competence training programme.

The trust had put in place a 9-point plan to address the issues identified in the 2025 report. These were in the early stages of being actioned at the time of our inspection and included plans to establish a strategic EDI group, develop a new workplace adjustment process, and provide dedicated support to the trust’s staff networks. Whilst work was taking place to introduce new initiatives, we saw little evidence of embedded change and/or feedback of sustained improvement.  

Staff networks had been built to promote equality, diversity and inclusion. All staff networks had an executive sponsor although discussions were ongoing for 2 of the networks to ensure the sponsors were the most appropriate. The trust had 3 staff networks which were:

• Workforce race equality network (WREN)
• Rainbow Alliance - The trust's LGBTQ+ network
• Disability and Wellbeing Network (DaWN)

We spoke with representatives from each of the staff networks.

WREN and DaWN were both being led by interim network chairs who spoke of the difficulty in recruiting permanent chairs. The WREN chair was also the new EDI lead. Both networks had been stood down for several months due to the lack of chair and had only recently resumed, with recruitment for permanent chairs ongoing. Representatives reflected that they felt the WRES and WDES results had been impacted by the networks’ lack of availability and felt positive that improvements could be made going forwards. WREN and DaWN chairs were looking to bring the networks together to enable them to carry-out the role most effectively. They described a low attendance previously, with plans to encourage this going forwards.

Rainbow Alliance described a more embedded network with stable attendance. The chair discussed the impact on staff of a recent high-court ruling and shared that the executive team had been supportive and provided assurances and support to staff.

DaWN members had fed-back about experiencing stigma in relation to disabilities within the organisation, with this differing between managers. Network members shared a desire to increase visibility going forwards through the introduction of disability champions.

All 3 network chairs described positive relationships with the executive team valuing their contributions. Chairs were given 2 days per month for the role and explained that this was originally 1 day which had been increased following their feedback. Across all networks there was also an appreciation for the engagement of the FSUG who regularly visited the network meetings to promote avenues for staff to have their voices heard. Members reflected that work was ongoing to identify the most appropriate executive sponsors and felt this was a positive step forward in promoting the work of the networks.

The trust employed an equality, diversity, and inclusion (EDI) lead who had been in post since September 2025. They were working with the Health Inequality team and reflective on the positiveness of collaboration. Since starting in the role, the EDI lead had been working to build foundations and trust with colleagues and teams. They described trust staff as passionate about EDI and wanting to see change and action. The EDI lead had worked to develop new governance structures for the reporting of EDI agenda items, as previously there was no action plan or clear reporting structures in place. They felt that the importance of representation across senior leadership was something that needed to be addressed and felt that a lack of board diversity could sometimes be a barrier, as reflected in the most recent staff survey and WRES and WDES outcomes. It was clear that whilst passionate about the role with clear ideas for improvement and support in place, there was a lot of work to be done to embed the change in culture and new ways of working.

Partners were positive about the commitment demonstrated by leaders to supporting equality, diversity and inclusion. They gave an example of the Trust Involvement Team who supported people with a learning disability to achieve paid posts within the trust.

The trust monitored gender pay gaps and the board received an annual report. The data for 2026 evidenced the trust’s gender pay gap had lessened since the previous year. In 2019, the first publication of gender pay gap information, the median gap was 4.4%. Most recent results in 2026 showed this was now 0%. The national median gender pay gap for full-time employees is currently 6.9% so the trust was well below this figure.

Leaders told us they were aware of the risks relating to EDI and subsequent culture and the need to address this moving forwards.

The trust had clear responsibilities, roles, and governance structures but our findings from other key questions and inspections of ASGs evidenced that these governance and assurance systems were not always operating effectively across the trust. Governance systems in place did not always ensure high quality service delivery and oversight. There were ongoing issues with fire safety, estates, out of area placements, and safeguarding processes which meant that the trust did not always work effectively with partners and were not entirely effective in managing and mitigating risks.

The trust governance framework comprised 7 board subcommittees which provided oversight, scrutiny and assurance to the board. Subcommittees included audit, finance and performance, quality, workforce, mental health legislation, renumeration and nomination committees. Board subcommittees, supported by both executive and non-executive directors, formed the primary assurance mechanism, and these were underpinned by 16 executive-led working groups, including trust wide clinical governance, estates steering group, executive risk management group and trust wide safeguarding committee, which enabled the board to maintain oversight of risk, quality and organisational control.

The trust also had several meeting structures which sat within their Governance Assurance Accountability and Performance (GAAP) framework to enable oversight of risk across the organisation. These included;

- Executive Risk Management Group (ERMG) meetings which took place every other month, chaired by the CEO and attended by all Executive Directors, Associate Director for Corporate Governance, relevant governance leads with responsibility for risk management, and the Deputy Director of Operations, in additional to periodical attendance from the Trust Head of Internal Audit (Audit Yorkshire), to ensure effective line of sight and management of risks across the organisation.

- Executive Performance Oversight Group (EPOG) meetings, a sub-committee of the Executive Management Team, which took place 6 monthly with Executive Directors, leadership teams for the relevant service line/department and relevant business partners to review key areas of performance across domains of service delivery, workforce, quality and safety, risk, issues and areas for unblocking and support. These meetings had been stood down due to demand on services over the winter period but were due to re-start following ASG inspection feedback.

- Executive Management Team (EMT) meetings, which took place monthly, with the CEO, all executive directors or deputies, and the Associate Director for Corporate Governance to provide oversight for ERMG and EPOG meetings.

Minutes from EMT and ERMG meetings evidenced appropriate levels of attendance and constructive challenge from attendees. However, whilst terms of reference for the EPOG made its' intended purpose clear, we were concerned that the last EPOG for rehabiliation services in October 2025 had not identified concerns found during the ASG inspection in March 2026.

Clinical governance information flowed through the clinical governance reporting structure. Each service line held local clinical governance meetings considered ‘tier 3’ meetings. These then reported into Unified Clinical Governance Group (tier 2) where there was representation of all service line leadership teams. This in turn reported to the trust wide Clinical Governance Group and then to Quality Committee.

At the time of our inspection, the trust was in segment 3 of the NHS Oversight Framework (NOF) ratings for non-acute trusts. NOF Level 3 indicates a trust the requires organisational support as the trust or board are performing below average across multiple areas and requires a coordinated improvement response. This was due to relatively low performance in 2 of the 5 domains within the NOF segmentation methodology: namely the ‘people and workforce’ and ‘effectiveness and experience’ domains. The reasons for this were related to staff sickness absence rates and the percentage of adult discharges with a length of stay above 60 days. The trust was conscious of these deficits, which had been of concern for some years, but we could see little demonstrable change in this time, with action taken failing to drive improvement.

The trust’s board assurance framework (BAF) was structured in line with national NHS guidance. Strategic risks were clearly described, with initial, current and target risk scores, and were assigned to strategic objectives. Mitigating actions for controls and assurance were documented for each risk. The BAF was embedded into governance processes and was a standing agenda item across the sub-committees of the board. Strategic risks and association controls were discussed, as were any actions required.

The BAF detailed 7 strategic risks with the highest rated risks noted as: ability to plan and deliver services for health needs of the population, digital technologies, and adequate care and working environments. For each risk, gaps in assurance and/or controls were detailed along with actions and target dates for completion. Each risk was assigned for oversight and management to an executive board member and to the responsibility of a sub-committee of the board. The Executive Risk Management Group had oversight of all trust risks, with specific focus on the strategic risks and risks rated 15 or above, of which there were 14 at the time of inspection. Whilst oversight of risks was evident, we found that the underlaying actions detailed in combined risk registers, which were required to mitigate risk and drive improvements in the quality of care, were not always effective.

In 2024 the trust commissioned an external and independent well led governance review. Whilst the review was largely positive there were some recommendations, including a recommendation that the trust considered further development of the BAF including a review of BAF risks, consideration of the board’s approach to risk appetite, and an assessment of risk mitigations. The review also noted that “the BAF Dashboard showed little movement other than risk escalation. This may indicate the mitigating actions in place are not sufficient to mitigate the stated risk”. This supported what was identified during our inspection with regards the link between the combined risk registers and BAF.

The trust had a process for gathering, analysing and escalating performance data in an accessible format to the board consistently and regularly. On a quarterly basis the board received a detailed ‘organisation priorities report’ detailing progress against the trust’s 15 identified areas. The report identified areas that were at alert, advise, and assure to evidence defined milestones that were being met, required escalation and to give assurance that a priority was on track. This allowed committees to sight the board of any areas of non-compliance or where issued required addressing urgently. Whilst the report identified current performance, it was not as clear to identify trends and performance changes over time.

The trust had systems to ensure the board’s committees had performance data relevant to their areas of focus such as mortality, Infection Prevention and Control (IPC), staffing, and incidents. However, whilst we identified that committees received reports providing information and reassurance in relation to risks, these reports lacked key information and clarity on how actions proposed would be effective in reducing risk or making improvements, and challenge or curiosity around these measures was not always evident. This included risks in relation to fire safety, out of area placements and length of stay, estates and environments, safeguarding, mandatory training, and staff survey results and culture.

“Risk of fire due to lack of compliance with trust fire safety protocols” had been on the corporate risk register since June 2025 and had most recently been reviewed in February 2026 whereby the risk remained “extreme”. In April 2026, the audit committee reviewed a health and safety report which reflected on key areas in relation to fire safety. An average compliance figure was shared of 76% which was a combination of all levels of fire safety training. However, compliance with Level 3 training, which was required by inpatient staff and was the highest level of training offered to frontline staff, was much lower at 64% across the trust and was as low as 54% in the acute service. These lower figures were not shared which meant the committee were unable to scrutinise training figures effectively. We were also concerned that whilst the trust had been aware of the low training compliance since December 2025, due to short notice withdrawal of the training provider, there was no plan in place to address this until April or May 2026 at the earliest. The update provided to audit committee highlighted a training plan whereby capacity of sessions planned should lead to 85% compliance if staff attend, but as of 22 April 2026 only 197 staff were booked onto training out of 499 who were non-compliant. This level of detail was again not provided, and therefore not scrutinised at the committee. We were concerned at the pace of action taken, given that between April 2024 and March 2025, 27 fire related incidents had been recorded across the trust. The trust was identified as the fifth highest trust in the country for fire-related incidents that year. The trust estates lead suggested many of these incidents were related to smoking rather than fire, but the data we reviewed showed this was not the case. Between April and December 2025 there had already been a further 24 fire related incidents reported across the trust, suggesting a lack of action to address the risk. The board were aware that the smoking related policy was not reviewed in line with the trust’s review date and minutes from a meeting of the executive risk management group in March 2026 confirmed “a plan was not in place” to address this. Clinical environment group meetings also demonstrated limited oversight and limited actions taken to drive improvement. For example, it was noted in November 2025 that 752 fire related actions were outstanding across the trust, but in March 2026 that had only reduced by 55 to 697. That is despite it being documented that over 200 actions had been completed between January and February 2026. There were a general lack of concrete improvement plans in relation to fire safety, and plans made lacked clear oversight or concrete timescales.

The trust continued to experience pressure from long lengths of stay and delayed discharges. Trust executives were well aware of the pressures, with the risk rated as “extreme” on the corporate risk register and detailed in the BAF due to risks to financial expenditure and reduced flow across inpatient areas. The trust had implemented an executive 'improving patient flow' programme; aimed at receiving assurance on the work to reduce out of area placements. More recently one of the trust’s 15 organisational priorities between April 2025 and March 2026 was in relation to their “inpatient quality transformation programme” which measured performance against the out of area placement trajectory. Progress reports reviewed for July 2025, November 2025 and January 2026 lacked detail on how this risk was being addressed, with minimal improvements seen and reports continuing to say this was “off trajectory” and “still an issue” without any concrete plans to drive improvement. A piece of work around inpatient flow, carried out in 2024 into early 2025, saw a decrease in the number of out of area placements, but these were not sustained and figures once again increased with no current clear direction for driving improvement apart from to commission an external review. Despite being aware of the risks, there were a general lack of concrete improvement plans or scrutiny of these at committee or board level.

In relation to the staff survey we found several metrics had declined since the previous year, with a continued poor uptake in terms of responses. Teams were encouraged to create their own ‘intention plans’ detailing how they would drive improvement, and the report on these plans went to workforce committee. We reviewed these and found that scrutiny of the focus and effectiveness of plans from the committee was lacking. Following our on-site element of the inspection, the trust themselves has identified “As part of our ongoing review of the Intention Plan process, we have identified the need to strengthen assurance around escalation and governance arrangements. While clear guidance has been provided to services on how Intention Plans should be reviewed and escalated through existing governance structures, there is currently limited evidence to confirm that this is being applied consistently across the organisation”.

We found that whilst escalation via committees to the board was routine, significant risks were not consistently highlighted. Overall, we found committees did not robustly challenge and did not consistently demonstrate ownership or pursue solutions for identified risks.

The Trust did not have good oversight of their estates and equipment and risks relating to the fabric of the buildings and environment were not sufficiently mitigated. The Trust estate was largely owned and managed under a Private Finance Initiative (PFI), meaning that the trust did not own the buildings from which they provided services. During ASG inspections, we found that this led to issues with ensuring environmental works were reported effectively and carried out in a timely manner. On the long stay or rehabilitation mental health wards for working age adults we identified issues including a lack of running water in a bedroom sink, lights not working, 2 toilets constantly flowing water, a blocked toilet, a soiled and uncleaned sink and mould around a bedroom window frame. Once made aware of the issue regarding mould the trust did take action, including treatment of all potential mould areas, a full redecoration, installation of new flooring, and specialist cleaning of the window. Monthly environmental walk arounds and estates logs were in place, but we found these were not effective in escalating and resolving environmental issues or ensuring required maintenance and/or repair work was completed. We also found ligature points and blind spots on the acute wards for adults of working age and psychiatric intensive care units which had not been identified by staff and therefore had not been appropriately mitigated. Governance systems in place had not ensured these risks were escalated and so senior leaders were unaware of these concerns.

The trust had an internal clinical audit plan detailing annual priorities covering areas including NG tube feeding, falls, and record keeping. The trust participated in national audits such as in eating disorders and psychosis. The trust had a ‘Clinical Audit Procedure’ detailing the importance, process and management of actions.

The trust demonstrated effective governance of the Mental Health Act (MHA)  with strong oversight to ensure people’s rights and safety. The mental health legislation committee received regular updates from the Mental Health Legislation Operational Steering Group. They reviewed Mental Health Act reports, discussed themes, and had a good understanding of the requirements of the code of practice. They received performance reports about the use of the MHA and MCA, reviewed these accordingly, and escalated to committees and the board where appropriate. An audit carried out by Audit Yorkshire in 2025 in relation to the MHA found high assurance, with one minor action around staff compliance with training. Whilst adherence to the MHA was largely found to be compliant in the ASG inspections we conducted, we did find that training compliance was below what trust would expect (74%) on wards for older people with mental health problems.

However, whilst the outcome of the external audit found high assurance with regards to the MHA, there was work to be done to address concerns in relation to the MCA. An outcome of an audit of mental capacity assessments and best interest decision documentation carried out by Audit Yorkshire in 2024 found limited assurance that capacity assessments evidenced compliance with the MCA requirements. The trust followed a subsequent recommendation that further audits of capacity assessments be carried out every 6-months. A re-audit in February 2025 found there were still areas of deficit, particularly in relation to the majority audited not containing a full description of the information that the assessor had provided to the service user about the decision to be made, a lack of evidence of the support offered to the service user to aid them to understand the relevant information and lack of detailed rationale sufficient to explain how assessor(s) had reached a particular conclusion. Recommendations were made largely in relation to staff training and future repetition of the audit. Despite re-audit being advised every 6 months, this had not taken place, and we were concerned about the governance oversight of the work required. Whilst adherence to the MCA was largely found to be compliant in the ASG inspections we conducted, we did find that on the long stay or rehabilitation mental health wards for working age adults there was a lack of best interest meeting discussion and recording for a patient whereby a capacity query was evident.

The trust’s annual positive and safe (use of force) report was finalised in June 2025 and provided a summary of the use of restrictive interventions in the trust between 1 April 2024 and 31 March 2025. The report outlined key initiatives such as Safewards, Positive Behavioural Support (PBS), Safety Huddle Coaching, and the use of the Safety POD. These initiatives were emphasised through the trust Positive and Safe Working Group (PaSWG), which was a proactive framework that sought to minimise the use of restrictive interventions through an emphasis on evidence-based approaches.

The report highlighted an overall 14% decrease in physical restraint from the year 2023/2024, as well as a continued reduction in the use of prone restraint (from 260 to 199 incidences). However, in the same time period, data showed an increase in incidences of rapid tranquilisation (420 to 499 incidences) and mechanical restraint (13 to 25 incidences). The trust had identified challenges in the higher use of restrictive interventions in specific services/wards including female acute wards and child and adolescent mental health wards and the trust Reducing Restrictive Practice Lead was able to describe initiatives to drive reduction including working closely with pharmacy staff around care planning and effective medicine prescribing, and implementing a revised approach to nasogastric tube feeding (delivering liquid food, water, and medications directly into the stomach through a thin, flexible plastic tube passed through the nose). Findings from ASG inspections were largely positive, with findings reflecting staff use of least restrictive options, restrictive interventions being correctly recorded, and lessons learned established where required.

The trust was a national early implementer site of the Patient and Carer Race Equality Framework (PCREF) and had an action plan in place (2024-2027) with annual progress and key objectives documented. Progress made in the financial year 2024/2025 was documented publicly on the trust webpages and detailed achievements including a PCREF project group having been established, and training on improving quality of data collection around protected characteristics being developed. EDI and Human Rights leads within the trust reflected whilst still in its’ early stages, implementation of PCREF was moving in a positive direction.

Overall, the trust demonstrated strong financial governance, good financial discipline, and a track record of delivery. In the financial year 2024/2025, the trust delivered its approved plan of £0.9m surplus. For 2025/2026, the trust submitted a breakeven plan to NHS England but later agreed through collaboration to improve its forecast by £0.926m to support the system in continuing to deliver a balanced position. The trust had not received Deficit Support Funding (DSF) in 2025/2026 and did not anticipate receipt in future years.

For 2026/2027 and for each of the two years thereafter (as per the medium-term financial plan) the trust had planned for compliance with operational planning guidance by submitting a breakeven plan and did not require Deficit Support Funding (DSF) in any of those years. The level of efficiencies specified for the 3 years was as follows: 2026/2027 £11.5m, 2027/2028 £12.0m and 2028/2029 £8.5m. Efficiencies were classified as either “fully developed” or “plans in progress” and fall within the range of 82% to 91% recurrent depending on the financial year under consideration.

The trust reported a £4.3m underlying deficit in its’ 2026/2027 financial plan. Additionally, the trust was holding a cash surplus to support the potential buy-back of the PFI contract. As described above, the trust had largely PFI estates, with PFI contracts expiring in June 2028. The contract was on a ‘buy or hand back’ basis on expiry. The trust had engaged with NHSE regional teams for several years regarding capital cover for this, which was escalated to the national team. Options had been discussed and it had been concluded that the only feasible option was for the trust to purchase the assets on expiry. The trust had planned well for this and had the cash reserves to support this purchase.

The trust maintained a stable executive team, with an experienced Chief Financial Officer in post for several years, supported by a finance team. The team had consistently submitted and delivered compliant financial plans in recent years. The trust had implemented significant efficiency schemes and had continued to engage in system-level collaboration, such as the West Yorkshire Mental Health Collaborative. An external audit of the trust’s financial statements was conducted for the financial year 2024/2025 and the subsequent report made no recommendations.

However, financial sustainability in some areas remained a concern. The trust provided an improvement plan to reduce out of area placements, which threatened to negatively impact trust finances, and were engaging with offers of regional and national support but to date there had been little demonstrable change. Additionally, the trust was also struggling to improve staff sickness which remained relatively high at 7.6% as of February 2026.

With regards medicines governance several areas for improvement had been identified. Pharmacy services went into business continuity between June 2022 to December 2024, with a trust medicines governance recovery plan being agreed in February 2025. A further, more extensive independent audit had been commissioned in April 2026 which was in draft at the time of our inspection. Similarly to draft report findings, we found that reporting and oversight of the medicines management assurance and controlled drugs audits could be strengthened to help ensure actions were addressed, to support ongoing improvement. Currently no pharmacy performance indicators were reported, but work was underway with the trust information team to understand medicines management information needs, design an operational dashboard, and extract data from the trust’s electronic patient record and medicines systems. Medicines governance was captured on the pharmacy and corporate risk registers as “high risk” and actions were detailed including an ongoing plan to recruit staff and a “1 year recovery plan” for pharmacy services and medicines governance with a target date for completion of July 2027. Independent audits of controlled drugs handling (2023) and of the management of secure stationery found significant assurance, with the trust recently completing work to address any recommendations.

The trust had identified a risk associated with their care record system. The system provider had concluded that they would not be investing in any further growth and would honour only essential maintenance and support for those within contract. Whilst the trust had identified the risk as extreme, the risk had not been formally reviewed since December 2025, and current actions were minimal and unclear. Trust leaders told us that the target implementation date for a replacement electronic patient record was July 2028 but that this may change dependent on the outcome of a planned merger with a local community trust. We were concerned about the pace of development given the current system provider status.

The trust had a process to respond to complaints from people using services. In the year February 2025 to January 2026 the trust received 180 complaints. All of these were acknowledged within 3 working days, as per the trust key performance indicator (KPI). However, complaints were regularly not completed within the timescale agreed with the complainant and the percentage compliance per month ranged between 50% and 93%. The trust had identified the need to improve and strengthen its’ complaints processes and as such had detailed concerns on the BAF as a risk and were implementing an updated complaints management procedure which was out for consultation at the time of inspection. The trust told us that the updated procedure would set out new KPIs which would be used to support transparency, accountability, and service learning across the organisation, including moving away from an agreed timescale with the complainant to a 60 working day timescale.

We asked the trust for copies of their annual complaints report that was sent to board. The trust told us that this report had been “temporarily paused while work was undertaken to streamline reporting processes and remove duplication” with the most recent report being produced for the financial year 2022/2023. The trust had instead produced quarterly combined reports which were presented to clinical governance group and the quality committee to enable themes, learning and assurance to remain visible. We reviewed the quarterly reports from April 2023 to December 2024 and found an average of 42 complaints per quarter, with variance between 34 and 52 complaints. Data was captured by service line and information about cases open to the Public Health Services Ombudsman (PHSO) was provided. Reports also captured outcomes, most common subject areas, and outcomes and learning at a basic level. However, this report did not provide information to fully interpret the data at a more detailed granular level.

The trust provided an Excel spreadsheet, pulled from their incident reporting system, which captured complaints and subsequent actions relevant to both staff and patients. The trust explained they utilised this spreadsheet to assist service line staff to monitor actions and learning arising from complaints. We reviewed this spreadsheet for complaints from July 2024 to December 2025 and found the spreadsheet was difficult to interpret, with some action due dates being before the date of the complaint being added to the sheet. This could indicate that complaints were not added to the spreadsheet in a timely manner. In this period there were 13 complaints relevant to the Children and Young People Services. Of these 13, 4 had not been allocated to anyone to oversee, despite being logged as far back as 10 December 2025. Following inspection, the trust told us these 4 complaints were linked but did not provide any additional evidence to demonstrate allocation or oversight to managing this complaint. Additionally, 7 of these complaints had associated outstanding actions which were past their due date, including one due for completion by 07 September 2024. This issue of incomplete actions past set deadlines was evidence for all services apart from the eating disorder and rehabilitation services, who were the only services to have completed all actions required in a timely manner. Within the forensic services there were 3 complaints that took 11 months to complete with no rationale for why these took so long.

We reviewed 10 complaints in detail and found all had received a response from the trust. Trust staff advised that timescales for complaint responses were discussed with complainants, but we could not see evidence of these discussions being routinely documented. In 5 of the 10 complaints the ‘Investigator Pack and Investigation Process’ was incomplete. The complaints policy was due for review in November 2025, but this had not been completed, but as above the trust did explain they were in the process of implementing a new policy at the time of our visit.

We also reviewed 5 Duty of Candour reports and found that 4 were not managed within trust policy timeframe. Whilst there were suggestions learning was identified it was not always clear what this learning was, and it was not shared with those involved in a way they could understand.

An external audit in November 2025 identified “low assurance” in relation to the handling of complaints and investigations. This included a concern of: “There is not a robust process to ensure actions arising from complaint investigations are designed to ensure a positive impact is achieved, or that actions are only closed when that positive impact is actually achieved.” This was listed as a “moderate” recommendation requiring action in terms of prioritisation. Whilst there was evidence of early progress against the audit recommendations, the information and evidence we reviewed did not provide assurance that actions from this audit had been fully actioned and embedded. We were concerned that whilst the trust was aware of the poor performance in terms of complaints management and were beginning to implement actions to drive improvement, actions were slow to progress.

Whilst our findings from ASG inspections evidenced there was a clear framework outlining the required discussions at ward, team and directorate level meetings, we found these were ineffective in ensuring quality of service provision and improvements were made. On wards for older people with mental health problems, 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 and had not ensured improvement had taken place in relation to a breach of regulation for failure to carry out physical observations, identified at a previous inspection.

Similarly on the acute wards for adults of working age and psychiatric intensive care units we found managers had not taken appropriate steps to ensure staff were adhering to infection prevention and control standards by being bare below the elbows and had not identified or taken action to address delays in the completion of physical health assessments.

Due to concerns identified following inspection of the long stay or rehabilitation mental health wards for working age adults we issued the trust a section 29A warning notice requiring them to make significant improvements in systems and processes.

With regards to safeguarding, we were concerned that the trust did not have systems and processes in place to monitor adherence with their internal safeguarding team advice. On the long stay or rehabilitation mental health wards for working age adults we identified that whilst staff were requesting advice when needed, they were then not always completing safeguarding referrals to the Local Authority when advised doing so. Trust safeguarding leads conceded that they did not have a mechanism in place to follow up on whether advice had been followed and following our feedback started to develop a process of addressing this. We were concerned that the lack of governance processes could potentially place patients at risk of harm in relation to safeguarding.

Feedback from partners was mixed in relation to this Quality Statement. One partner described clearly defined structures, whilst another reflected that the trust was risk averse with a limited understanding of the wider system impact of individual contract decisions. Another partner described a lack of information sharing with the board of governors and described difficulties with governance processes with the trust relying on out-of-area provisions.

There were processes to ensure the integrity and confidentiality of data, records and data management systems. The trust has an obligation to assess data protection and cyber security incidents against the NHS Digital methodology and report serious incidents to the Information Commissioner’s Office (ICO) and, for the most serious or large-scale incidents, to the Department of Health Social Care (DHSC). For the financial year 2024/2025 there were 4 incidents that met the threshold for reporting, 3 of which related to “inappropriate and unlawful access to patient data” and one to a “sub-contractor data breach”. Staff compliance with training in information governance was above 80% across the trust.

There were known business continuity plans for use when unexpected events occurred and created a risk to the delivery of the service. At the time of inspection, business continuity plans were in place for the adult eating disorders service and the child and adolescent mental health wards, and these evidenced actions taken to minimise risk to staff and patients alike.

Leaders at the trust invested time in building relationships, understanding perspectives and constructively engaging and collaborating with partners so that services worked seamlessly for people. 

The trust demonstrated a wide range of partnership working, both internally and externally, recognising that achieving its’ ambitions required close working relationships with a variety of partners. Leaders had taken on leadership roles within the local system, for example the trust was a key member of the Leeds Provider Partnership (LPP), launched in May 2025, for which the trust CEO acted as Senior Responsible Officer (SRO). This was a collaboration between NHS trusts, Leeds City Council, primary care providers and the voluntary sector aimed at improving people’s health, joining up care, and creating more local health services. They were also part of the Learning Disability Partnership Board where they engaged in discussion and shared updates and learning about what support was there for people with a learning disability. They also operated in partnership with the Leeds Mental Wellbeing Service (LMWS) to offer free psychological therapies and support for common mental health issues to anyone aged 17 and over who was registered with a Leeds GP.

Partnership working was evident across the trust’s strategy particularly in the underpinning ‘Care Services’ and ‘People’ plans. The trust prioritised working in partnership with, and collaborating with, those using services as well as partners externally, such as in the Integrated Care System (ICS).

Observation of trust board meetings, and review of board papers, evidenced a focus on the patient voice at the start of meetings, which the board then used to inform staff, influence board decisions, and improve service quality. The trust had also employed a Patient Experience Lead and Lead for Lived Experience to ensure the patient voice was heard and led to changes in care and service provision. A lived experience framework had recently been introduced alongside a strategic group and subgroups involving carers, patients and those with lived experience. Leads described an “increasing appetite to utilise those with lived experience to develop services”. Leads described a dashboard which provided oversight of which teams and services were involving lived experience members and how they were involving them in decisions about services. This also allowed the team to see where co-production was lacking and provide additional support to those teams/services to ensure the patient voice was heard.

The trust’s governors told us they felt supported to undertake their roles and represent local communities. They felt welcomed into the trust and received induction, training and support for their roles. Governors could access specific workshops and were supported to undertake visits to services. They told us they were able to make requests to be involved in specific areas of work and these would generally be facilitated.

The trust operated several Provider Collaboratives across Yorkshire and Humber and were the lead provider for perinatal mental health, adult eating disorder, and Tier 4 Children and Young People (CAMHS) services. These partnerships empower NHS providers to manage resources, and provide more seamless, community-based mental health care. However, whilst provider collaborative leads within the trust described key initiatives around reduced out of area placements, and patient length of stay, these initiatives were not replicated positively elsewhere in the trust.

Feedback from partners about the trust’s engagement with them was mixed. Whilst some partners described a “strong commitment to work in partnership with statutory, primary care and voluntary sector partners” others described a perceived “hierarchy of professions” with an inconsistent view of third sector providers coming from within the trust. One partner described an improving situation, with the trust hosting new partnership initiatives, but a historic lack of engagement and ownership for wider system issues within Mental Health that still required improvement.

The trust focused 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 trust had developed a collaborative approach to research, innovation, and quality improvement, led by an internal research department, with roles including Research Programme Managers, Clinical Research Lead, and Research Assistants, Fellows and Administrator. There were also 30 Research Champions across the organisation whose role it was to advocate for research in their service, inspire colleagues to get involved, and to bring research into everyday conversations. The trust’s research leadership was closely linked with both clinical and academic partners.

The trust’s research and development strategy (2022-2027) described the main objective of the department to “develop and deliver high quality research” with success being determined by “more high-quality research delivered across a broad range of service areas”. This was underpinned by the following strategies:

• developing a skilled research workforce;
• creating a culture of research being core business;
• actively engaging a network of key stakeholders;
• influencing national and regional agendas;
• effectively disseminating outputs and impacts of research.

The latest Research and Development Annual Report 2024-2025 detailed that the trust had recruited to 21 studies, opened 17 new studies, and recruited 276 participants to be involved in studies.

People using services were involved in improvement and innovation. The trust group, Help from Experts by Experience for Researchers (HEER), was a group of people with lived experience of mental health problems who were enthusiastic about research. Those engaged in research within the trust could utilise the time and expertise of the HEER group, from design to sharing of results, to producing better informed, more relevant and accessible research. The trust also had a group known as COMIC, or the Child Oriented Mental Health Innovation Collaborative, for those under 25 years of age as well as relevant professionals, youth and community groups, charities, CAMHS facilities and parent forums who advised on the work of the trust to ensure work was co-produced and user-led from beginning to end. The groups were overseen and supported by members of the trust research team. Over the two decades since its’ inception the HEER group had contributed to around 100 regional and national research projects.

The trust was actively engaged in a range of regional and national partnerships. For example, the trust was involved in a research study into genetic factors associated with severe mental illness, as part of The National Institute for Health and Care Research (NIHR) BioResource project into multiple disease areas. They were also involved in the National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH), identifying service users who had died by suicide whilst receiving mental health care in the previous 12 months to contribute to a bigger national picture about impact. The trust was also involved in research projects alongside universities and are leading on a multicentre study which will directly contribute to National Institute for Health and Care Excellence (NICE) guidance.

The trust provided information about research for staff via StaffNet, the trust internal website. This included contact details for staff should they wish to discuss ideas for research before committing to a project. The trust prioritised the development of research careers, particularly for nurses, through its’ Mental Health Student Hybrid Placement (MESH) programme which provided opportunities to experience research alongside clinical placement which counted towards placement hours. MESH involved a 6-week programme with 18 hours of research-focused sessions supported by the Research and Development team. The trust’s Allied Health Professionals (AHPs) created a yearbook in 2025 detailing projects and research activities undertaken by AHPs with the aim of promoting research and making it feel more tenable for AHP staff. Similarly, the trust produced a quarterly research and development newsletter called ‘Innovation’, celebrating the work of staff engaged in research.

Leaders described innovation to improve safety including the introduced of a Lead for Lived Experience role. As part of their role, they delivered a segment within trust Prevention and Management of Violence and Aggression (PMVA) training for staff to enable staff to “see there’s a person behind the restraint”.

The trust had used accreditation to ensure they were meeting definable standards in some areas of clinical care. This included accreditation by the Royal Collage of Psychiatrists for the community perinatal service and adult inpatient eating disorders service.

Partners were positive about the trust’s approach to learning, improvement and innovation. Partners told us the trust had a learning culture and provided some positive examples of how the trust have worked hard to improve outcomes based on feedback from those who use services.

The trust had systems to learn from deaths, inquests, patient safety incidents and alerts from national bodies. The systems were effective and highlighted learning that was disseminated and used to improve the quality and safety of care and treatments. The trust ‘Learning from Deaths Policy’ outlined the trust’s responsibility to review all deaths of service users that had been in receipt of care by the organisation at the time of their death or within 6-months since their discharge.

During the financial year 2024/2025 the trust reviewed 1,070 deaths. 15 of these deaths were reported to StEIS (NHS England Strategic Executive Information System). Of those incidents 9 were reported as per the Serious Incident (SI) Framework and 6 were reported as per the Patient Safety Incident Reporting Framework (PSIRF) (which replaced the SI framework in July 2024). [GB1] The trust Learning from Incidents and Mortality Meeting (LIMM) was held weekly and was where all deaths and serious incidents were reviewed. From here a decision would be made by attendees, utilising the trust’s Learning from Deaths Policy, as to whether a further type of review, such as structured judgement review, after action review, specialist thematic review or concise investigation, was in scope. The meetings were chaired by the Head of Clinical Governance, and any risks, issues, themes or good practice were escalated through the trust Incident Review Group chaired by the Medical Director. Of the deaths reviewed during the reporting period detailed, 91 required further review and 2 were established as being due to problems in the care provided to the service user.

The trust told us that in line with PSIRF the timescale (KPI) for completing Patient Safety Incident Investigations (PSII) was 6 months as reflected in the trust PSIRF policy. We asked the trust for a list of all ongoing PSII’s, and the trust provided a list of 13, of which 10 had not been concluded within the trust timeframe. One incident classed as “severe” had been open since October 2024 and another whereby a death had occurred had been open since December 2024. It was unclear what had caused the delay in investigations, and we were concerned about the trust’s ability to learn from deaths and serious incidents in a timely manner. However, findings from inspections of ASGs evidenced staff demonstrated robust incident management and received timely learning from incidents locally.

In the 12 months prior to the well-led review the trust had received 1 prevention of future death report (Regulation 28) from HM Coroner. After an inquest, if a Coroner believes that action should be taken to prevent future deaths, they have a statutory duty to issue a Regulation 28 report. This report is sent to any person, organisation, or authority that the coroner believes has the power to take such action. The trust had responded to the report received, demonstrating clear actions had been taken to reduce the likelihood of recurrence.

Leaders were aware of the trust’s impact on environmental sustainability. They were able to provide examples of where the trust had made changes to reduce the trust’s carbon footprint.

The trust’s Chief Financial Officer was the board level executive lead for sustainability. The trust had recently refreshed its Green Plan (2025-2030) which had been board approved, and leaders ensured a carbon footprint of services was undertaken to help inform their approach to reducing carbon over each cycle of the plan. There was evidence of positive challenges from the board to ensure the plan was, and continued to be, ambitious.

The trust’s Green Plan outlines their strategy to:

• Achieve net zero carbon emissions ahead of NHS targets.
• Embed sustainability across all services and operations.
• Work collaboratively with staff, service users, and partners.
• Deliver care that is environmentally responsible and future-proof.

Leaders showed an understanding of the importance of appropriate governance for sustainability. The Green Plan steering committee met quarterly to track progress which was then communicated up to the Finance committee and eventually board for Green Plan sign off and review of progress annually.

The Green Plan management group oversaw delivery across nine key workstreams: workforce and system leadership, sustainable models of care, digital transformation, travel and transport, estates and facilities, medicines, supply chain and procurement, food and nutrition, and adaptation.

The group split their targets into scope 1, 2 and 3 emissions and outlined a pathway to achieve success. Successes so far have meant 40 to 50% of actions had been achieved. The board had placed climate change on their risk register and were considering and developing plans for cost-effective mitigations and options to reduce excess summer heat in estate buildings.

Staff engagement in the trust’s Net Zero goals was identified as a challenge. Although the trust attempted to communicate about sustainability, such as through internal intranet pages, it was noted that it could be challenging to get staff involved in sustainability projects. The most recent staff survey also highlighted that a high number of staff were not aware of the trust’s sustainability goals and there was poor uptake of learning modules which were available, but not mandatory, for all staff. However, there was a plan of how to drive improve in this area in the future, for example the sustainability manager was planning to attend team away days to discuss the work they were doing, and the trust’s Green Plan (2025-2028) detailed trust aims for staff training year on year including the trust aim for the financial year 2025/2026 to have 5% of staff certified ‘Carbon Literacy for Healthcare’ training, increasing to 10% the following year.

Partners were aware that the trust had a Green Plan. The trust plans were aligned with wider system plans, particularly the local Integrated Care Board Green Plan. The trust was also clearly engaged with local partners around sustainability, for example with procurement partnerships and attending workshops for the Leeds climate commission. The trust had been successful in securing bids to fund Green Projects from the NHS and was committed to working with partners to ensure community project funding in the future.