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

The governance processes in place were not fully effective. Managers and leaders had not ensured mandatory training compliance in a range of areas. There were medicines management issues at Red Kite View which did not appear to have been picked up through the audits and checks that were in place, and these had not been escalated to and acted on by managers.

Nevertheless, there was a clear shared vision, strategy and culture based on equity, equality and human rights, diversity and inclusion, and engagement. Staff and leaders understood the needs of people and their communities and worked together to meet them.

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.

Staff understood the organisational vision and values, and could give examples of how they applied them in their work. They understood the work that the service was supposed to be carrying out and what they hoped to achieve.

Some of staff said they saw senior managers on the ward, others did not comment on this.

At Red Kite View, one manager described a slight divide between the nursing and occupational therapy teams, which included teams not always being in attendance together at meetings and de-briefs. This was not raised by other staff.

Overall, staff felt supported by their ward managers and local managers. There was openness and awareness of the common principles. Staff felt supported by their managers. They understood the service values and how they related to their work.

Managers’ offices were based on the ward communal areas, so they were seen to be accessible and inclusive. There was a range of meetings that encouraged engagement and a strong culture. There were regular staff meetings, nursing meetings, senior nurse meetings, multidisciplinary team meetings and clinical meetings. There were local operations meetings for each young people's service, and joined up managerial meetings for the whole of CAMHS for the trust. There were further opportunities for engagement in reflective practice, debriefs and safety huddles. Staff received regular management and clinical supervision where they could discuss best practice and values. There was a strong culture of caring for the patients; for example, a care plan was adapted for a young person to create bespoke treatment and give her a better quality of life. Staff went to great lengths to engage and communicate in ways that met her needs. They also arranged external support from another service provider.

Managers and leaders we spoke with appeared knowledgeable and passionate about their roles and we did not identify any individual concerns about their capability.

They understood their roles clearly and how this fed into the running of the hospital. Managers had clearly defined roles and these were explained throughout staff and manager interviews.

Staff that we spoke with said senior managers were supportive. Some said they saw senior managers on the wards supporting them in their roles.

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

Staff survey responses to leadership questions were generally more positive than they had been the previous year.

Leaders were compassionate, open and honest. They were inclusive and encouraged a strong culture that represented the provider’s organisational values.

A number of staff had been supported to develop and advance within the services, which demonstrated their choice to work there and meant the service retained a stable workforce.

Managers were visible within the service. They knew the staff and the young people well. They encouraged staff to talk if they had concerns.

There was a range of training courses available to managers to support and develop their competency, including the ‘Manager 360’ course. Other courses included recruitment and selection values-based training, managing conflict and managing teams.

Staff told us they felt confident raising concerns to their managers, either through handover, team meetings or an individual basis.

There was an annual staff survey where staff could provide feedback anonymously.

There was a freedom to speak up (FTSU) guardian and we encountered no evidence to suggest this process was ineffective in any way.

There was information on display about how to contact the FTSU guardian.

Incidents were reported appropriately.

Young people, their families and carers were able to give feedback, which managers and staff used to make changes.

They also had opportunities to be involved in making decisions about the service, such as staff recruitment.

Managers told us the workforce was reflective of the demographic of the local population.

No staff raised concerns regarding the service not making reasonable adjustments or implementing flexible working arrangements. Managers gave examples of arrangements made for individuals for a range of reasons.

Managers confirmed arrangements available to support workforce wellbeing, such as occupational health referrals, referral to other services if required, and wellbeing discussions and de-briefs after incidents. More regular arrangements included management and clinical supervision.

We did not find any human rights concerns. We did not encounter any concerns related to the gender pay gap. Training compliance for equality and diversity was above 90%.

Staff we spoke with understood their roles and responsibilities. They knew how to report concerns. Lessons learned were disseminated; for example, at meetings with staff.

They said leadership was good and supportive, and the managers were effective.

We identified issues with the governance systems for monitoring and managing medicines. Whilst there were audits and monitoring processes in place for checking medicines, there were gaps in fridge and room temperate checks at Red Kite View. In addition we found that wards at Red Kite View had out of date medicines or missing equipment. We were not assured that managers had sufficient oversight of medicines management procedures and had not taken appropriate action to resolve these issues.

Nevertheless, we observed handovers, safety huddles and a reducing restrictive practice meeting, and saw that this gave managers and staff the opportunity to discuss young people and their current risks, provide updates and agree actions.

Organisational policies were up to date, comprehensive and provided guidance for staff that was specific to the service. There were systems to ensure staff reported incidents appropriately. The provider kept data on incidents which managers reviewed at monthly clinical governance meetings.

There were designated meetings and procedures for agreeing and amending staffing numbers, including points of contact for who to go to if numbers needed to increase. There were monthly clinical governance meetings.

There were processes that ensured senior leaders had clear information about risk, performance, and young people’s outcomes.

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

Managers told us about the provider collaboratives they were part of, which met every month. They described robust clinical conversations within the collaboratives. They also met every week with another CAMHS service.

Staff described links with other services and providers to support young people’s recovery, such as community teams, day services, social services and other hospital departments such as paediatrics.

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

However, records we reviewed showed that the provider had links with external independent organisations that supported young people in their recovery.

Care records and interviews with staff confirmed that the service worked with a range of stakeholders throughout each young person’s journey on the ward.

Managers described professionals’ groups, the West Yorkshire provider collaborative and various other work with external stakeholders.

In addition, managers met regularly with care coordinators and commissioners and external professionals; for example, there were monthly meetings with the local authority safeguarding team. The service liaised and met monthly with the NHS women’s pathway. They also met every fortnight with the independent mental health advocate.

The service registered young people with a local GP on admission. A physical health nurse also visited the ward to assess physical health needs and refer to external services where required.

There was an improvement plan in place for Red Kite View which had actions to address key areas of service delivery including mandatory training. This was reviewed by managers and leaders regularly. Staff told us about a range of training available to them, which included courses specific to the service. Student nurses told us they learned a lot from the staff. Trainee staff from other departments also worked in the service. 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. Staff told us about debriefs following incidents or concerns, which provided opportunities for learning, making changes and improvement. There were regular reflective practice sessions and clinical supervision where issues could be discussed. Staff described a culture of identifying and making improvements. 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. The service monitored effectiveness via clinical audits. There was a priority plan that included audits of observation and engagement within inpatient settings and care plans. The service provided examples of quality improvement initiatives, such as clinical supervision evaluations report, cinemotions group, AMBIT sessions and the Re-QUEST patient reported experience measure. The provider conducted serious incident investigations that identified actions and learning. The service had action plans that served as the main approach to assessing and reviewing actions from audits, lessons learned, incidents and near misses. The plans were reviewed in clinical governance meetings. The provider implemented a sensory audit tool, with input from young people. There were a number of recommendations related to improving the environment, changes to make and development that staff needed. As a result, the provider made changes to provide a better environment. Some staff had completed sensory integration training. Following a care plan audit, the provider had made changes.