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

Staff and managers worked together to create an inclusive and positive culture of continuous learning and improvement. Managers were open, honest, and encouraged both staff and patients to provide feedback on the service. Leaders proactively supported staff and collaborated with partners to deliver care that was safe, integrated, and person-centred, and sustainable. Overall, there were effective governance and management systems in place and, information about risks, performance and outcomes was used effectively to improve care. Staff were supported well with numerous well-being resources enabling them to perform their roles to the best of their ability which enhanced the care and support given to patients. However, staff training compliance was not always effectively monitored, and some staff were not up to date with all their required training.

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 on the ward said there was a strong team ethos and set of shared values amongst the team. They talked about ‘keeping it simple’ which was one of the trust’s values. They mentioned the care pathway and what the service aimed to do. This pathway was pictured as a colourful tree and was visible on the ward to patients staff, and visitors. The service had a one-page plan which was last updated in April 2024, and shared with staff in a range of ways. The trust had an equality, diversity and human rights' policy and provided training to staff on this. Managers planned to further train staff in cultural competence.

The ward atmosphere was welcoming and calm. Staff were engaged in positive interactions with patients and their families. The feedback from patients on the ward was highly positive, and the team culture created an environment of collaboration, trust and respect.

Staff said the management team were very skilled experienced and supportive. They told us they had good access to training & development and managers were approachable. However, feedback from leaders identified that some staff did not have timely access to mandatory refresher training because of higher than usual staff sickness. Staff thought the management team were professional and inclusive. They had access to a monthly business meeting and minutes were circulated for those that could not attend.

Ward managers were supported by a more senior service manager, who took part in some ward duties, and who understood the needs of service users and staff. Managers had access to management development training and staff were supported with reflective supervision and de-brief.

Staff said they would have the confidence to speak up if needed and that the trust’s freedom to speak up guardian visited the ward regularly. They said they felt able to challenge how things were done and, where appropriate, they could challenge each other in a supportive way. We were not aware of any whistleblowing concerns, but there were posters in staff areas and on the staff net about freedom to speak up.

The trust had Managers had revised the staff induction handbook to include information about raising concerns and the role of the freedom to speak up guardian and speak up ambassadors on the ward.

Staff were supported in relation to their well-being and had not experienced any harassment or discrimination. The trust were proactive at ensuring flexible working arrangements were in place, and managers made reasonable adjustments where needed. Managers had access to appropriate human resource support for recruitment, performance management and occupational health support. Relevant policies and procedures were in place to support this.

Staff had access to a handbook, which identified all the well-being support in place for them. This included occupational health, counselling and therapy, medical welfare, critical incident support, recovery college and financial support. The trust had an up-to-date equality, diversity and human rights policy in place including a Workforce Race Equality Standard, (WRES) and a Workforce Disability Equality Standard, (WDES), and gender pay gap reporting statement.

Staff and managers held governance meetings with the trust’s perinatal community services and in-patient services to ensure the appropriate communication and pathways between the different services. The ward manager undertook one shift per month to keep in touch with issues on the ward and to monitor the quality of care at ward level. This also included attending multi-disciplinary meetings.

The ward had a risk register in place which quantified the risk and had mitigation/remedial plans in place with timescales. However, it was not comprehensive. There was only one set of risks identified concerning ligature risks. There were no issues identified with the higher levels of sickness being experienced on the ward, or with some mandatory training compliance being below the trust target. Risks were discussed at governance meetings. The ward had an up-to-date blanket restrictions log which was regularly reviewed, but we did not see that these had been reviewed with patients. However, there were plans to reduce the restrictions on patients having access to some rooms that were currently locked. The ward held regular business meetings with staff and these fed through to regular leadership meetings. Issues were escalated as appropriate to bi-monthly governance meetings. All meetings had clear standard agendas in place with discussion on relevant issues. However, compliance for individual training courses was not monitored closely enough so leaders did not identify that training compliance was slipping for some courses. By the time of our inspection, some mandatory training compliance had fallen to below 60%. When we inspected medicines management at the service, there was no T28 certificate in place, which, is a legal requirement and allows controlled drugs to be denatured on the provider’s premises. However, immediately following our assessment visit, the trust showed us evidence to confirm that they had since complied with this requirement.

Patients were supported to keep in touch with people involved in their care, for example, their care coordinator. External professionals, including care co-ordinators were encouraged to attend multi-disciplinary meetings.

Managers understood the importance of positive working relationships with external partners, and worked closely with other services and commissioning teams to improve and develop the service. Stakeholders and partners confirmed that staff worked in collaboration with them, and they were responsive to discussing referrals at any time. Staff had good links with other teams in the trust, including the perinatal community teams, the community mental health teams and safeguarding teams.

Feedback from partners confirmed that staff had collaborative partnerships with internal and external stakeholders.

Staff had a strong partnership with the trust’s community based diverse parents group that parents from the Leeds area could be referred to. The service had written information in place for patients, as well as information available for potential referrers including a virtual tour.

The manager reported that there were lots of opportunities for staff to be involved in quality improvement projects if they wanted to be, and that they were provided with support and training. Staff also had access to an internal team that provided support and debrief to staff following a critical incident or untoward event.

Staff were encouraged to be involved in quality improvement work and gave us examples, such as a project to improve care planning and involving patients in the process more fully.