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

The ward was clean, well furnished, and well maintained. The service provided care and treatment in a way which made patients feel safe, supported and listened to. Staff minimised restrictive practices, and managed risks well. They understood how to protect patients from abuse, and had training on how to recognise and report safeguarding concerns. People were supported to make choices that balanced risks of harm with positive choices about their lives. The service used systems and processes to safely prescribe, administer, record and store medicines. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.

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.

Patients felt listened to and were encouraged to feedback any concerns they had about the service.

Staff reported all incidents and discussed patient safety at handover meetings. Feedback from patients was used to improve the service.

The levels of incidents and complaints were low, but managers analysed incidents regularly for themes and trends. They investigated all incidents thoroughly and provided feedback to staff through team meetings, and via electronic communication. There were examples of positive changes staff had made as a result of learning lessons from incidents. Staff felt supported by the management team to raise concerns, and had access to a trust-wide freedom to speak up guardian. All staff had access to reflective supervision.

Patients told us staff shared information with appropriate community teams to ensure they got the right support. They received visits on the ward from their midwife and other professionals involved in their care.

Staff made sure babies completed their mandatory immunisations and checks.

The stakeholders we spoke with confirmed that the ward operated safe systems of care and ensured continuity of care, including when people moved between different services.

Patients received an induction to the ward when they were first admitted, and had access to written information about the ward.

Patients and their partners/significant others told us they felt safe and protected from abuse.

Staff demonstrated a good knowledge of safeguarding processes and knew how to identify and report safeguarding concerns.

We observed staff carrying out care and treatment in a way that protected patients from abuse, harm and neglect.

Staff attended monthly safeguarding supervision sessions and were up to date with training in safeguarding children and vulnerable adults. Staff also completed mandatory training in ‘Prevent’, and compliance rates for this were high. Prevent is a national program in the UK that aims to prevent people from becoming terrorists or supporting terrorism. The trust had an up-to-date safeguarding policy in place and staff liaised effectively with the internal safeguarding team. Staff made sure the safeguarding team were aware of every patient admitted to the ward and sent them an internal summary on discharge. A specialist perinatal social worker worked with the team one day per week, and had input into patient reviews where this was relevant.

Patients told us they felt safe and supported on the ward and staff supported them to manage risks. They had access to written information about restricted items on the ward. They told us staff were skilled at de-escalation techniques and incidents of hands on restraint were rare.

On admission to the service, all patients had a perinatal risk assessment, and, depending on the risks identified, some also had a safety plan. Patients were assessed prior to going on leave and this included risks to the baby. Patient risk was managed through observation levels dependent on level of risk, which was agreed by a multi-disciplinary team. Leaders told us patient observations were completed, and that staff had been trained to undertake this task. Staff utilised a least restrictive approach, attempting to use de-escalation and distraction techniques before using physical intervention when incidents occurred. Patients at risk of self-harm were supported to identify triggers and early warning signs and make advance statements about the use of restrictive interventions. This was contained in their safety plan. Staff took part in meetings aimed at reducing restrictive practice.

The service had an in-depth standard operating procedure and a blanket restrictions log, which was reviewed at clinical governance meetings. Work was being undertaken to make locked areas more accessible for patients, for example, by fitting anti-barricade doors, and reducing ligature risks. However, despite the guidance on the standard agenda, we did not see evidence that blanket restrictions had been discussed with patients in their community meetings either in June, July or August 2024. At the time of our inspection, three out of the eight bedrooms did not have keys available for patient use, however, the manager confirmed that more keys had been ordered so each patient could have their own room key. Patients also had free access to safe outside space directly off the ward. We looked at restraint data, and, in the six-month period between April and August 2024, and there were six incidents of physical restraint. There were no incidents of high-level floor restraint. Staff reported they never used prone, (face down) restraint. In the same period, there were no incidents of patients being administered rapid tranquilisation. Staff completed accredited training in using restraint techniques, but compliance levels were low at 55%. The trust told us that staff had been trained, but some staff had not completed re-fresher training, and this was largely due to a period of staff sickness. Following the inspection, the trust supplied us with an action plan to improve compliance. We saw examples of positive risk taking, which allowed patients to take part in activities that were important to them, but that did not compromise their safety.

Patients confirmed they had access to a nurse call system in their room and staff always responded very quickly. They were happy with all the facilities and equipment to help them care safely for their babies.

Staff carried out weekly checks, for example, fire safety checks, general health and safety checks and the trust’s health & safety department carried out quarterly audits and desk top training exercises with staff on the ward. Business continuity plans were in place including for adverse weather and power outages. Staff had access to up-to-date hard copies of essential care documents for patients in the event of IT systems failures.

Staff regularly checked the emergency resuscitation equipment in the clinic room to ensure it was suitable for use as required. We had no concerns about safety when we toured the ward environment.

The trust had a suicide prevention risk assessment and survey in place to reduce the number of ligature points on the ward. Many of the fittings, particularly in patient bedrooms and bathrooms were anti-ligature fixtures, but some rooms that staff considered to be high risk remained locked until patients wanted to access them. Patients were supervised according to their level of risk. Managers had an action plan to reduce the risks in these rooms to allow unsupervised access for patients.

The patients we spoke with said staff were extremely responsive when they needed help and there was always staff around. One patient told us they were enough staff most of the time, but there had been a couple of weekends where staffing was low. The partners we spoke with said they thought the staff were capable and competent in their job role. Patients thought staff were very knowledgeable about perinatal care.

The trust had an escalation procedure to make sure the ward was safely staffed at all times. Staff at night or weekends could contact on-call manager who would ensure safer staffing levels were maintained. Agency staff were not trained in perinatal care, but they were only used as a last resort and we did not receive any negative feedback from patients about staff knowledge. The ward had 5 nursery nurses, working the early and late shifts 7 days per week. Two of the nursery nurses also work nights, however, the nursery nurses did not cover the ward 24 hours per day in line with national guidance. There was a sufficient level of medical cover with 1.0 whole time equivalent (wte), consultant psychiatrist, 1.0 wte specialty doctor, and resident doctors on the ward. At trust level, there was a duty rota, which meant a doctor could attend the ward in an emergency within 30 mins 24 hours per day.

There were few staff vacancies and staff retention was high. We looked at staff rotas and safer staffing reports. In last 12 months, there were no incidents where numbers fell below the trust’s minimum staffing levels, which were 5 staff for early and late shift and 4 staff night shift. Those numbers increased if patient acuity was high.

There was always at least one qualified nurse on shift day and night and data from the trust confirmed this. Managers used agency staff and a pool of bank staff to cover sickness and other absence. Agency staff use was low and in the last 12 months, only 2.87% of shifts were covered by agency staff. Bank staff were used more frequently and 29.02% of shifts were covered by bank staff in the previous 12 months. Bank staff were trained in specialist perinatal care in addition to the general mandatory training received by substantive staff. The mandatory training staff received was comprehensive, but compliance levels were low for some of the refresher training courses. We asked the provider to send us an action plan to improve compliance with mandatory training.

Patients told us the ward was clean, tidy and well maintained. They said cleaning staff were present on the ward every day. No-one raised any concerns about infection control or staff not wearing personal protective equipment when required.

Staff were confident in using the trust’s infection control procedures, and had good access to personal protective equipment. They confirmed they had annual training and audits were in place. They told us they were very careful about hygiene procedures especially with having young babies on the ward. The manager told us they had an external cleaning company who carried out all the cleaning. Feedback meetings were held to address any concerns, but, overall, staff and patients were happy with the cleaning arrangements.

We toured the ward and found it to be clean and well maintained. We observed staff paying appropriate attention to infection control procedures.

Clinical and non-clinical staff had annual infection control training and compliance rates were high, 100% for non-clinical staff and 93% for clinical staff. The trust had a separate infection control team who carried out regular audits, and overall compliance with standards was high with no concerns.

People told us they got their medicines when they needed them and that they were reviewed often. They told us they got print-outs with medicines information and had been prescribed other medicines to help with side effects. One person said they had some concerns about medicines, but staff took their concerns seriously and responded to reassure them.

Staff had to undergo annual training with 100% pass mark, and all staff who administered medicines had been assessed as competent to do so. Meetings between pharmacy staff, prescribers and patients took place as needed. In the 12 months prior to our inspection, there had been no serious medicines errors. Patients and their partners/significant others were invited to regular multi-disciplinary meetings, where their medicines were reviewed by appropriate clinicians.

All clinic rooms were well stocked with relevant well-maintained equipment available for use, and patients' medicine cards were completed correctly.

Medicines were stored, managed and dispensed in line with national guidance, except the trust did not have a T28 certificate in place at the time we were on site. This is a legal requirement if controlled drugs are being denatured on the premises. However, at the time of our inspection, there were no controlled drugs on the ward, and immediately following our visit, the trust registered for their T28 certificate. A Pharmacist visited the ward when there was a new admission and/or if they were invited to patients’ multidisciplinary review meetings, and Staff had access to relevant patient medicines documentation, including information on patient allergies