Leeds and York Partnership NHS Foundation Trust

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

Young people’s needs were assessed before admission, with input from the multidisciplinary team to ensure the provider could meet them.

Young people had opportunities to join in planning their care and treatment. The provider gave them information so they were able to make choices and decisions.

Discharge plans were clear. Young people and staff worked together to plan goals and aims for discharge.

The provider recognised and met communication and cultural needs.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The young people we spoke with told us how their needs were met and how involved they were in treatments and activities.

Staff described how they ensured young people’s care was person-centred and met their individual needs. They provided one-to-one care and groups with the young people. They also told us about working with other professionals, such as psychologists and occupational therapists.

Care and treatment focussed on getting young people to a point where they were well enough to return to the community.

We saw that staff provided extra support if it was needed, such as at mealtimes.

The records we reviewed showed that care plans were developed with input from young people, their families and carers and considered their needs and preferences.

Care plans met the needs of individual young people. They ensured choice and continuous care. Young people’s needs and preferences were fundamental to the delivery of person centred care.

Care was arranged with other services and providers, including interacting with young people’s families and carers. Records included plans for discharge, such as how care and treatment would be followed up and support continued.

Staff supported young people with communication and cultural needs. There was a multi-faith room. An advocacy service was available.

Young people had opportunity to be involved in plans for the service via the young peoples’ council.

The young people we spoke with told us they could be involved within the wider community such as volunteering and work opportunities. Some young people chose not to engage with this. Where appropriate, young people maintain links with their schools and continued their education.

Managers described how the pre-admission process involved external services. They also told us about links with home treatment teams, crisis teams and consultants during admission.

They would facilitate a speedy admission in a crisis and develop an initial care plan based on referral information. An out of hours consultant would review out of hours referrals. They could admit patients late at night if needed.

We did not speak with provider partners about this quality statement.

Records we reviewed confirmed the young people could access external services, such as a local GP, dentist and other community health services when they were needed.

Interviews with staff and managers, and care records reviews demonstrated that staff tried to involve external teams wherever possible. External teams were invited to care programme approach meetings and multidisciplinary team meetings. They were part of the admission and discharge process.

The young people we spoke with told us they had copies of their care plans if they wanted them. They said staff provided them with information in ways and formats they could understand.

Easy read versions of information leaflets were available.

Staff told us about arrangements to facilitate communication for a young person who was deaf. Some staff had completed British sign language courses.

A learning disability nurse also worked closely with the young people to help ensure their needs were met.

The service provided information to young people, such as timetables, information about their care team, section 132 rights, advocacy, and information about how to meet their religious, spiritual and cultural needs.

Managers also described arrangements they had made to facilitate communication with a young person who was deaf.

There were translation services available, and young people could access information and leaflets in a variety of languages and formats to meet their needs.

Young people we spoke with told us they were given information about their rights and about treatment.

They said they had choices and options in treatment and were involved in decisions about their care. However, some said they chose not to engage. Some said they did not have opportunities to give feedback on the service they received and some told us the staff asked them to provide feedback. One said they provided feedback to the multidisciplinary team meeting.

Some young people said they did not have any involvement in decisions about the service, such as recruitment, although we saw notes of young people’s council meetings that described their involvement, such as designing interview questions and being part of the interview panel. Another young person told us how they were involved in the meetings.

We did not speak with any parents or carers about this quality statement so did not gather their views.

Staff said they would feel safe to raise concerns. They understood processes to do so. They told us about opportunities to speak up, such as in reflective practice, clinical and managerial supervision, debriefs and safety huddles.

The minutes of young people’s council meetings described their involvement, including in staff recruitment.

Records we reviewed showed young people’s involvement in planning their own care.

Young people’s council meetings were held every month. There was discussion around various topics, such as use of phones and activities. One young person had been involved in interviewing for staff, and others had helped set the post criteria and write the interview questions.

Young people were involved in care planning, with their views and wishes being documented routinely.

The provider investigated and monitored complaints. During the year up to this assessment, there were three formal complaints made to the provider and three concerns raised via the Patient Advice and Liaison Service.

There were no concerns about access to advocacy.

The patient survey showed that all questions asked resulted in a partially true or certainly true response. There were no concerns evident from the survey results.

The provider had already started work on the suggestions for improvements, such as amending admission booklets and multidisciplinary team feedback for young people, increasing staff training around neurodivergence, and expansion of current care pathways available.

Staff had participated in annual staff surveys. Between 2022 and 2023, satisfaction had increased in most areas. Some staff reported feeling burnout, being unable to meet conflicting demands on time and that team members did not always understand each other’s roles.

There was a strategy for carer involvement that set out current activity, plans for the future and set out approaches to enable ongoing conversation and support from carers.

Young people said they felt supported and their needs were being met. They could access the care they needed when they needed it.

Staff had access to relevant training, including learning disability and autism, to enable them to understand and support young people. They described how they had accessed support for a young person with communication challenges. However, uptake of training across the service ranged from 59%-81%.

Staff told us that young people could access the service when they needed it, including in a crisis or out of hours.

We did not speak with provider partners about this quality statement.

The premises were accessible. Both units were situated on the ground floor. There were accessible entrances, all on one level. There was also lift access.

Young people had access to support post-discharge. Staff ensured s117 aftercare where required.

Managers told us the service arranged temporary accommodation for young people if needed. They also put them in touch with the Barnardo’s children’s charity, and they could access family therapy in the community, as well as the home treatment teams and support following discharge.

The provider had carried out an audit of the sensory environment that young people had been involved with.

A learning disability nurse worked closely with the young people to help the team meet their needs.

The young people we spoke with did not express any concerns about equality or discrimination.

The provider had undertaken some work to look at equity in experiences and outcomes, specifically in relation to the environment at Mill Lodge. This was a sensory environmental review aimed at evaluating and improving the environment to try and ensure it met the needs of young people with sensory impairments. Recommendations included dimmable lights, quieter alarm sounds and doors that closed more quietly to reduce noise.

Staff gave some examples of how they adapted support to meet people’s needs, such as facilitating visiting a culturally appropriate barber, and providing food and diet to meet cultural needs.

The inspection did not highlight any barriers to care due to protected characteristics etc. We did not identify any inequalities in experience and outcomes.



Staff received training in equality and diversity. They also received training that enabled them to recognise and address potential radicalisation risks.

They encouraged a positive culture where young people, their families and carers felt able to speak up.

Young people told us how they were involved in planning their own care and treatment.

Staff told us they focused on getting young people well enough to return to the community. This included education around their difficulties, coping skills, and helping them to express their difficulties, such as naming and understanding their emotions.

They also described building trust and relationships, and reflecting on how they communicated.

Planning for discharge started at the point of admission. Young people developed goals for their treatment on admission. Staff supported them to plan ahead to be able to achieve those goals.

Young people had clear discharge care plans with defined objectives identified for discharge.