Leeds and York Partnership NHS Foundation Trust

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Mandatory training compliance was low in several areas. Managers audited training records but had not taken adequate steps to address areas of non-compliance. At Red Kite View, we identified medicines management concerns. This included medicines checks not being routinely completed, medicines and equipment that had expired or was missing, and errors in medicines recording. Some staff told us that the service had a proactive and positive culture of safety based on openness and honesty. Other staff told us they felt concerns about safety were not always listened to. Nevertheless, there were processes in place to ensure safety events were investigated and reported thoroughly, and lessons were learned to identify necessary changes to practice. There were clear processes in place for identifying, recording and escalating safeguarding concerns.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not speak with young people using the service about this quality statement.

There was a clear and established culture of learning. Staff told us about training available to them, which included specific training in eating disorder and meal support. Agency staff also received training in safeguarding and prevention and management of violence and aggression before starting work at the service. Student nurses told us they learned a lot from the staff. Occupational therapy apprentices worked in the service and said they felt integrated in the team while they were learning. Learning was encouraged for career advancement. Managers gave examples of staff who had progressed through the band levels. Some had been given funding to support them through the trainee nurse associate course. All staff completed information governance training before being given access to systems. Staff told us about debriefs following incidents or concerns, which provided opportunities for learning. We saw examples of lessons learned from incidents and audits, such as environmental changes being made to reduce sensory stimulation, and adaptations to care planning.

There were processes to identify concerns across the service and facilitate learning, such as reporting incidents, training, supervision, meetings where essential information and learning was shared. There was a quality improvement plan in place and staff could access up to date policies or speak with managers if they needed support or guidance.

Members of the psychology team had developed The Red Kite Questionnaire for Understanding Experiences of Services Together (Re-QUEST), a new patient reported experience measure (PREM). It was developed following the low response rate to the PREM in use at the service, to promote understanding of young people’s experience of mental health services in measuring the quality of care and creating a service where they can feel safe.

Young people using the service told us they were involved in their care.

Staff and managers described the process they followed up to and during admission, which corresponded with records we reviewed. This included awareness of the complexity of each young person and the group already admitted, and consideration of the psychological impact of treatment on the newly admitted young person and on others. They told us that discharge planning began on admission. They told us about discussions of progress and long-term plans, including with the provider collaborative, Mental Health Act staff and restrictive practice leads. Care records confirmed that young people had discharge plans. Staff told us the service was commissioned for short term crisis work, so they concentrated on getting young people well enough to be able to return to the community. We spoke with a psychologist who told us that interventions focused on formulation, assessment and stabilization, getting young people to a point where they were safe enough to move on. This included education around their difficulties, coping skills, helping them to express their difficulties and understand emotions, so that they could engage in therapy.

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

We did not identify any concerns throughout the inspection regarding transition between different services. A young person at Red Kite View was in the process of transferring to supported living and had a plan to support their moving on.

To ensure continuity of safe care, staff followed a standard process for admission, transfer and discharge. They completed a pre-admission assessment for children and young people, with input from nurses and other professionals. This included information such as safeguarding information, capacity to consent, rationale for referral, support needs, including communication needs, and goals for the admission.

Young people were admitted from community, the section 136 suite, out of area beds, referrals from families, community and children’s crisis teams.

Young people already admitted to the service took part in ‘sunrise’ meetings for mutual help, including mindfulness, and staff would share with them at this meeting if there was to be a new admission.

Care records showed that young people and staff worked together to identify objectives and goals to prepare them for discharge. Interviews and care records showed that there was a clear focus on recovery. We saw that discharge planning began on admission, with input from young people and their family or carers. The service also worked with external teams to plan and facilitate transfer and discharge. They invited external teams to multidisciplinary team meetings.

Young people had clearly defined pathways. Our discussions with managers and review of care records demonstrated partnership working throughout young people’s pathways. There was regular liaison with bed managers, community teams etc.

The young people we spoke with said they felt safe and had not experienced any aggression.

However, some family members had concerns. They thought there were a lot of bank and agency staff, and that not all the staff were friendly, which had impacted on their child feeling distressed.

Staff understood the processes for making safeguarding referrals, they knew what to report and who to report it to. They described some safeguarding concerns and how they had been dealt with, including lessons learned. The ward managers told us they reviewed safeguarding alerts, carried out fact finding and fed back to the senior management team. They described how the safeguarding lead investigated alerts, identified actions and liaised with the local authority. Actions were cascaded back to the ward. Managers kept a log of all safeguarding referrals made. There was a dedicated safeguarding team that supervised safeguarding concerns and reviewed management plans developed in response. The staff we spoke with thought the team had good oversight and was effective. The Purposeful Inpatient Admission meetings had a standing agenda item for mental capacity. When we spoke with staff, we did not identify any concerns with their understanding of the Mental Capacity Act.

The safeguarding procedure was available to staff including contact details for the local authority. The inspection team did not identify any human rights infringements during the inspection. There were no young people who were subject to Deprivation of Liberty Safeguards. We did not identify any concerns related to harassment and abuse. We did not identify any sexual safety concerns.

There was a detailed safeguarding strategy that set out a clear system for staff to follow and provided guidance.

There were safeguarding logs that showed the provider monitored the number and types of referrals and identified actions.

Managers had oversight of and reviewed all safeguarding alerts. There were identified safeguarding contacts at the local authority.

A member of the senior leadership team took the lead on investigating safeguarding alerts, identifying actions and liaising with the local authority. Actions were then cascaded back to the ward.



Safeguarding was a standard agenda item at clinical governance meetings.



There was a safeguarding policy that provided guidance for staff, which was subject to regular review.

At the time of assessment, Mill Lodge had over 90% compliance for training in safeguarding children, level 1 and 3 and safeguarding adults, level 1 and level 3.



However, for the psychiatric intensive care unit (PICU) at Red Kite View, safeguarding adults level 3 and safeguarding children level 3 were both at 67%. Nine out of 27 staff had not completed the training.

Young people told us they were offered copies of care plans, although most chose not to take one. They and their family members said they were offered choice and involved in decisions.

Staff described positive risk taking. This included the reintroduction of items that had been removed from young people to help keep them safe. They developed individualised plans to try and reduce risks.

We could see how young people’s choices and independence had been taken into consideration. Staff told us they met with them and their family members or carers when they were admitted. They talked with them to help understand them and their concerns.

We reviewed a sample of observations records for the young people on Skylark and Lawping ward and saw that they were fully completed, with the observations being carried out within the prescribed timescale. The forms specified the level of observation required and entry of observation of behaviour, manner, mental state and interaction. We also reviewed the provider's audit of observations records that identified whether the procedure for therapeutic observations and engagement was being adhered to and any areas within the procedure for improvement. Care records showed that risks were assessed on an individual basis, with any restrictions relating to the needs of the individual. The risk assessments we reviewed were detailed and reflected young people’s current risks. They were updated regularly, including following any incidents. The records corresponded with discussions noted in multidisciplinary team meetings. We could see from care records reviews and staff interviews that some risks related to nasogastric feeding. Other risks included challenging behaviours, violence and aggression, self-harm and boundaries. At Mill Lodge, staff enabled young people to access their bedrooms subject to a risk assessment. Managers reviewed staffs’ observations competency during supervision. The nurse in charge conducted daily checks of observation records to ensure that staff were completing and recording observations appropriately. Training compliance in preventing and managing violence and aggression ranged from 88%-100% across the sites. Managers provided examples of positive risk taking, such as facilitating leave, ground leave and access to money.

The young people we spoke with did not raise any concerns about the safety of the environment.

Staff understood incident reporting procedures and reported safety issues. Lessons learned were taken to the clinical governance meetings.

Staff and managers told us the young people had personal emergency evacuation plans (PEEPs) to ensure they could evacuate the building safely.

At Mill Lodge, we discussed the blind spots on the ward with staff, who told us they felt they staffed the wards accordingly. They gave an example of one young person who was on eyesight observations, with an additional member of staff due to their violence and aggression risk.

At Mill Lodge, there were some blind spots in the corridor near young people’s bedrooms. These were mitigated by observations and staff positioned around the unit. Many of the doors at Red Kite View did not automatically close. We were advised this was caused by the supply and fitting of the doors. This was recorded on the risk register with actions in place to mitigate the risk. This included clinical staff checking that doors were closed and the estates team considering alternative solutions to ensures the functionality of the doors. Managers had ongoing going discussions with the supplier and contract of the doors to try and resolve the issues. Nevertheless, we were concerned that this posed a security risk and staff confirmed there had been several incidents whereby young people and staff had trapped their hands in the doors. On the PICU at Red Kite View, we found that the courtyard had been out of use for several weeks due to graffiti and damage to brickwork. The young people all had access to a second outdoor space. Staff had reported this to the estates team and the trust confirmed that this issue had been resolved approximately two weeks after the inspection."

Managers completed regular quality ‘walk rounds’ on the wards. They also carried out environmental audits and risk assessments that identified hazards such as potential ligature points, windows needing restrictors, storage of cleaning products and items that may be ingested. The audit included a record of what action had been taken to address any identified risks and the date completed.

The environment at Red Kite was a circular design overlooking an enclosed outdoor area. Staff could see patients along the corridors and in the garden area through the glass corridors.

Furniture and wall fixings were set on magnets or had anti-ligature design features. Clothing hooks in bathrooms were smooth and flexible.

The wards were clean and the furniture was in a good state of repair.

There was a fire safety evacuation procedure and the units had fire extinguishers and fire blankets. Staff received fire safety training and knew what to do in the event of a fire. The young people all had individual personal emergency evacuation plans (PEEPs).

Staff received training in skills such as preventing and managing violence and aggression, fire safety, health and safety and life support.

We could see that the provider had taken action to mitigate incidents, including injuries and young people going absent without leave.

Most young people felt safe and told us there were enough staff on the wards. No-one had had leave, therapy or activities cancelled due to staffing levels. However, a small number of young people told us they didn’t feel safe. They raised concerns about restraint and staffing numbers. One young person said there had been times when they could not find a member of staff. One parent said they thought the ward was understaffed at weekends and evenings. Several young people told us that staff on night shifts fell asleep during the shift.

Staff told us that working at the service was a positive experience. They described feeling welcomed and integrated into the team. At Red Kite View staff said the new ward manager and new matron were very experienced, had good relationships with staff and felt they would have a positive influence in leading them. Managers at Red Kite View told us that recruitment and retention of the staff team had been challenging and recognised that staff needed to feel supported.

Staff at both Red Kite View and Mill Lodge described working closely with other departments, such as the psychology and occupational therapy teams during multidisciplinary team meetings and care planning meetings. Staff said there were opportunities to speak out and raise concerns during reflective practice, clinical and managerial supervision, debriefs and safety huddles.

We observed that staff appeared busy throughout the inspection, particularly at Red Kite View. It appeared that some staff struggled to complete tasks or had time to engage with patients. Nevertheless, staffing numbers had been met and there were staff available to support people with section 17 leave.

Staff data for the previous 6 months showed that the wards were overstaffed more often than being understaffed. Use of agency staff averaged 9%, alongside 19% for bank staff and 71% for substantive staff.

Sickness and turnover varied between units and fluctuated monthly. Turnover had decreased in the three months prior to inspection.

Red Kite View had a high number of vacancies. 43% of nursing and health care assistant roles were vacant on the psychiatric intensive care unit. This was 38% for the general admission unit. Nevertheless, we did not identify any direct impact to care, and managers had taken action to advertise and recruit into vacant posts.

We reviewed a sample of seclusion records. Staff had completed the relevant observations, nursing and medical reviews; however, on one occasion a second member of staff had not added their signature to the entry for nursing review.

Staff received regular supervision and an annual appraisal. However, we found areas of non-compliance for mandatory training at Red Kite View. For example, immediate life support training ranged from 38%-80% across the service. Fire training compliance ranged from 100% at level one, 80%-100% at level two, and 50%-74% at level three. Learning disability and autism training also varied between teams, ranging from 59% - 81%. We were concerned that these areas of non-compliance could impact on staff’s ability to understand the patient group and their ability to meet young people's needs.

Young people and their family members told us that communal areas, bathrooms and bedrooms were always clean.

Staff told us that communal areas, bathrooms and bedrooms were cleaned on a regular basis.

We found the wards were clean and well maintained.

There were cleaning rotas and adequate supplies of cleaning products, handwash and personal protective equipment on the wards.

We did not identify any concerns with food hygiene.

There was an infection prevention and control policy that provided guidance for staff. It was up to date and reviewed regularly.

The young people we spoke with said they were given information about their medicines. Some said they were involved in reviews but others could not remember.

Family members agreed and some said they were also involved.

Staff and leaders could describe the process for the supply, storage and disposal of medicines. They could explain what checks were in place to monitor medicines and equipment. Staff knew where to locate prescription records and treatment certificates. At Ted Kite View, one member of staff told us about an incident when an oxygen mask was missing, and one had to be borrowed from another ward.

We identified some medicines management concerns at Red Kite View at both the psychiatric intensive care unit and general admission unit. Staff did not always complete the appropriate fridge and room temperature checks. On the general admission unit, nine checks were missing for March 2024, five for April 2024, four for May 2024 and five for July 2024. There were also several missing checks for the psychiatric intensive care unit.

Some medicines had expired. On the general admission unit, the emergency bag contained adrenaline which had expired in June 2024. On the psychiatric intensive care unit there were blood bottles and MRSA swabs that had expired. There were no emergency drugs, and it was not clear whether these had been taken to another ward.

On the general admission unit there was no oxygen mask of the appropriate size. Staff needed this in response to an incident which took place during the inspection and had to locate a mask from the psychiatric intensive care unit.

We found medicines recording errors. The emergency drugs list on the trolley in the general admission unit stated that medicine had expired in August 2023. The medicine itself was in date and was due to expire in August 2024.

There were processes in place to monitor medicines management. Managers told us they had oversight of medicines management with weekly input from the pharmacy team who completed medicines management assurance checks every three months. However, these processes were not effective as they did not identify the concerns we identified with fridge and temperature checks, expired or missing medicines and equipment, and medicines recording errors at Red Kite View.